Health and life sciences medicaid high performance capability assessment

ABSTRACT

A high-performance capability assessment model helps a Medicaid program meet the challenges of the health market. As a result, the Medicaid program can achieve the clarity, consistency, and well-defined execution of core processes that reduce inefficiencies and waste that result from unnecessary process complexity and exceptions. In addition, the high-performance capability assessment model helps the Medicaid program to identify specific areas in which improvements may be made, to understand how to make said improvements, and to establish levels of capability along the way to reaching an ultimate capability goal.

BACKGROUND OF THE INVENTION

1. Technical Field

This disclosure concerns a system and method for identifying the performance of an organization on a scale of mastery across representative capabilities of the organization's industry. In particular, this disclosure relates to an efficient and cost effective way to assess the performance level of key capability areas within the processes of a Medicaid program.

2. Background Information

Modern Medicaid programs operate in an increasingly challenging environment. To survive, Medicaid programs must adapt to this environment and execute in a clear, consistent, and efficient manner. Furthermore, the competitive nature, regulatory requirements, low profit margins, and competitive challenges of Medicaid programs greatly increase the complexity and difficulty of surviving on a day-to-day basis.

Despite the need for Medicaid programs to meet the challenges of the health-related market, it is still often the case that the programs lack clarity, consistency, and well-defined execution of its core processes. These shortcomings severely constrain the programs, and lead directly to inefficiencies and waste due to unnecessary complexity, process exceptions, and customer dissatisfaction. At the same time, it can be very difficult to identify specific processes to which improvements may be made, either because the program management itself does not have the expertise to identify the processes or because the complexities of the programs frustrate attempts to clearly delineate the processes to be improved.

Even if the Medicaid programs, on their own, could identify one of the many processes that it needs to improve, the business or management would not necessarily know how to improve the process or be able to identify a concrete and measurable improvement goal. Another difficulty exists in determining whether there are any intermediate goals that should be reached along the way. As Medicaid programs struggle to meet the demands of the modern economic and health landscape, they fail to identify opportunities for maximizing efficiency, category expansion, multi-channel execution, customer satisfaction, and to reach other important goals.

Therefore, a need exists for an efficient and effective system and method to assess the performance level of key assessment areas within the processes of a Medicaid program.

SUMMARY

A high-performance capability assessment (HPCA) model helps a Medicaid program meet the challenges of the market segment by defining a scale of performance mastery along which the current practices of the program may be located. The HPCA model accelerates the discovery of process and performance gaps within program operations. In addition, the HPCA model also helps the program to identify specific areas in which improvements may be made, how to make the improvements, and how to establish performance measures during the course of attempting to achieve an ultimate goal. As a result, the programs can achieve the clarity, consistency, and well-defined execution of core processes that maximize the operating budget for optimum outcomes.

The HPCA model includes a key factor dimension and a performance mastery scale dimension. The performance mastery scale dimension defines multiple mastery levels. The performance mastery levels form a scale of increasing organizational performance. The scale includes a ‘Basic’ mastery level, a ‘Competitive’ mastery level, and a ‘Market Leading’ mastery level along a horizontal axis. Each performance mastery level includes criteria specific to a corresponding key assessment area. Each key assessment area identifies some aspect of a capability of a Medicaid program.

A capability can be defined as a bundle of closely integrated skills, knowledge, technologies, and cumulative learning that is exercised through a set of processes and that collectively represents an program's ability to create value by producing outcomes and results. Capability areas do not represent a delineation of organizational responsibilities because the outcomes of a capability may be the result of a number of cross-functional teams. Capabilities of a business may be grouped into areas and/or platforms, including platforms and sub-platforms, depending on the organizational structure of the business.

For example, the HPCA model groups the capabilities of the Medicaid program into nine main areas or platforms, which may also be thought of as “program areas,” namely a program management platform, a care management platform, a contractor management platform, a program integrity management platform, a business relationship management platform, a provider management platform, a member management platform, an operations management platform, and an enterprise platform. Each platform may include multiple sub-platforms. For example, the program integrity management platform may include three sub-platforms, namely an identify candidate case sub-platform, a manage case sub-platform, and a payment integrity sub-platform.

Some of the platforms and sub-platforms may include additional or further levels, while others may not, and may also include capabilities at their lowest level. Examples of capabilities within the program quality management sub-platform include, for example, a manage business performance capability and a manage quality, risk, and performance capability.

The key factor dimension establishes a set of key assessment areas in which to analyze the capabilities of a business. Key assessment areas include performance capability criteria. Performance capability criteria populate the performance capability assessment model. The performance capability criteria may be specific to any one of many different business capabilities. Any number of performance capability assessment models and performance capability criteria may be defined and stored in a capability detail pool for subsequent retrieval and application to a business under examination. Accordingly, the HPCA model provides a flexible and adaptive scale of performance capability against which business practices may be compared to ascertain where the capabilities of a program under examination fall along the scale.

Other systems, methods, features, and advantages will be, or will become, apparent to one with skill in the art upon examination of the following figures and detailed description. All such additional systems, methods, features, and advantages are included within this description, are within the scope of the invention, and are protected by the following claims.

BRIEF DESCRIPTION OF THE DRAWINGS

The Medicaid high-performance capability assessment model and system may be better understood with reference to the following drawings and description. The elements in the figures are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the capability assessment techniques. In the figures, like-referenced numerals designate corresponding parts throughout the different views.

FIG. 1 shows a high-performance capability assessment model with a performance scale of mastery and performance criteria shown for different capabilities showing multiple platforms, including a program management platform, a care management platform, a contractor management platform, a program integrity management platform, a business relationship management platform, a provider management platform, a member management platform, an operations management platform, and an enterprise platform.

FIG. 2 shows a high-performance capability assessment model with capabilities for sub-platforms, including a program quality management sub-platform, a cost containment sub-platform, a program administration sub-platform, a budget sub-platform, a risk and issue management sub-platform, a policy management sub-platform, a program information sub-platform, an accounting sub-platform, and a benefits administration sub-platform, all corresponding to the program management platform.

FIG. 3 shows a high-performance capability assessment model with capabilities for sub-platforms, including a manage Medicaid population health sub-platform, an establish case sub-platform, a manage case sub-platform, a manage registry sub-platform, and a quality and outcomes reporting sub-platform, all corresponding to the care management platform.

FIG. 4 shows a high-performance capability assessment model with capabilities for sub-platforms, including a health services contracting sub-platform, a contract information management sub-platform, an administration contracting sub-platform, and a contractor support sub-platform, all corresponding to the contractor management platform.

FIG. 5 shows a high-performance capability assessment model with capabilities for sub-platforms, including an identify candidate case sub-platform, a manage case sub-platform, and a payment integrity sub-platform, all corresponding to the program integrity management platform.

FIG. 6 shows a high-performance capability assessment model with capabilities for sub-platforms, including an establish business relationship sub-platform, a manage business relationship sub-platform, a manage business relationship communication sub-platform, a terminate business relationship sub-platform, and a determine strategic alliances sub-platform, all corresponding to the business relationship management platform.

FIG. 7 shows a high-performance capability assessment model with capabilities for sub-platforms, including a provider enrollment sub-platform, a provider information management sub-platform, a provider support sub-platform, and a provider network management strategy sub-platform, all corresponding to the provider management platform.

FIG. 8 shows a high-performance capability assessment model with capabilities for sub-platforms, including an eligibility determination sub-platform, an enrollment sub-platform, a member information management sub-platform, a prospective and current member support sub-platform, and a market products and services sub-platform, all corresponding to the member management platform.

FIG. 9 shows a high-performance capability assessment model with capabilities for sub-platforms, including a service authorization sub-platform, a member payment information sub-platform, a claims-encounters adjudications sub-platform, a cost avoidance sub-platform, a cost recoveries sub-platform, a payment and reporting sub-platform, a payment information management sub-platform, and a capitation and premium preparation sub-platform, all corresponding to the operations management platform.

FIG. 10 shows a high-performance capability assessment model with capabilities for sub-platforms, including a health informatics sub-platform, a procurement management sub-platform, a privacy and compliance management sub-platform, a legal management sub-platform, a human resources sub-platform, an information technology operations sub-platform, and a facilities management sub-platform, all corresponding to the enterprise platform.

FIG. 11 shows a capability detail pool providing a multidimensional Medicaid program performance reference set where multiple key assessment performance reference tables are collected and stored.

FIG. 12 shows a capability assessment system.

FIG. 13 shows a flow diagram for establishing high-performance capability assessment models.

FIG. 14 shows a flow diagram for retrieving and applying high-performance capability assessment models.

FIG. 15 shows a flow diagram for analyzing representative practice data to determine a Medicaid program and Medicaid key assessment area to which the representative practice data applies.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

FIG. 1 shows a high-performance capability assessment (HPCA) model 100. The HPCA model 100 specifies nine platforms, including a program management platform 102, a care management platform 104, a contractor management platform 106, a program integrity management platform 108, a business relationship management platform 110, a provider management platform 112, a member management platform 114, an operations management platform 116, and an enterprise platform 118. Each platform 102, 104, 106, 108, 110, 112, 114, 116, and 118 may include sub-platforms. The HPCA model 100 is not limited to the form shown in FIG. 1. Instead, the HPCA model 100 may be adapted and modified to full a wide variety of analysis roles. Additional, different, or fewer platforms may be used in other implementations, with each platform defining additional, different, or fewer capabilities. Each platform and/or sub-platform includes one or more multiple <platform/sub-platform name>capabilities 130.

The HPCA model 100 establishes a multidimensional Medicaid program performance reference set that includes multiple key assessment performance levels 138, further described below in reference Tables 1-3. The performance levels 138 establish a scale of increasing effectiveness in delivery of each capability. The key assessment performance reference tables include a ‘Basic’ 140 delivery level, a ‘Competitive’ 142 delivery level, and a ‘Market Leading’ 144 delivery level. The performance levels establish a scale of mastery 146 along which current program practices may be located and identified with respect to any platform and capability within a platform according to an analysis of performance capability criteria (PCC). The capability under evaluation may be assigned the performance level 138 based on a delivery effectiveness position 158 along the scale of mastery 146.

The ‘Basic’ delivery level 140 specifies ‘Basic’ performance assessment criteria, the ‘Competitive’ delivery level 142 specifies ‘Competitive’ performance assessment criteria, and the ‘Market Leading’ delivery level 144 specifies ‘Market Leading’ performance assessment criteria. The HPCA model 100 receives input data that specifies a Medicaid program platform (e.g., a Medicaid program area) and a Medicaid program key assessment area for analysis. The HPCA model 100 searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program platform and corresponding program capability within the platform and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table. The HPCA model 100 initiates analysis of the matching key assessment performance reference table to obtain a resultant performance assessment level for the Medicaid program key assessment area.

Tables 1-3 below provide an explanation of each of the capability levels 140, 142, and 144.

TABLE 1 ‘Basic’ Delivery Level Description: Capability mastery at the basic level is competitive on a domestic or local level and selectively on a global basis.

TABLE 2 ‘Competitive’ Delivery Level Description: Capability mastery at a competitive level is in the top 50% of performers when compared to domestic and international peer groups.

TABLE 3 ‘Market Leading’ Delivery Level Description: Capability mastery at a market leading level implies that few companies globally are performing at this level, and can include emerging capabilities where companies have committed significant levels of investment and resources.

For FIGS. 2-10 the capability under evaluation may be assigned a level of mastery 138 based on the program's position along the scale of mastery 146 (e.g., the ‘Basic,’ ‘Competitive,’ or ‘Market Leading’ delivery level). Performance criteria corresponding to the basic 140, competitive 142, and market leading 144 performance levels populate the HPCA model 100. The performance criteria capture characteristics, and/or other features of the delivery of a capability at a particular performance level. Examples below illustrate performance criteria that provide analysis and benchmarking for Medicaid programs. The HPCA model 100 performance criteria provide a tool for determining where a platform and capability under examination fall along the scale of mastery 146.

For example, business consultants and business process engineers may interview a business or receive data about the business to determine, measure, or otherwise ascertain the characteristics, criteria, and other features of a particular capability implemented within the program. The consultants and engineers may compare the characteristics of the business to the performance criteria in the HPCA model 100 and arrive at an assessment level 138 for the capability under examination. In doing so, for example, the consultants and engineers may identify where the capability under examination falls in terms of the performance level for each key assessment area of a capability and determine an overall position on the scale of mastery 146 for the capability under examination. Performance criteria may populate the HPCA model 100 in whole or in part. Multiple high-performance capability assessments may be collected and stored with the performance criteria for future retrieval and possible modification in a capability detail pool, discussed below.

FIG. 2 shows the program management platform 102 divided into respective capability areas 202. The program management platform 102 includes a program quality management sub-platform 220, a cost containment sub-platform 222, a program administration sub-platform 224, a budget sub-platform 226, a risk and issue management sub-platform 228, a policy management sub-platform 230, a program information sub-platform 232, an accounting sub-platform 234, and a benefits administration sub-platform 236.

FIG. 3 shows the care management platform 104 divided into respective capability areas 302. The care management platform 104 includes a manage Medicaid population health sub-platform 320, an establish case sub-platform 322, a manage case sub-platform 324, a manage registry sub-platform 326, and a quality and outcomes reporting sub-platform 328.

FIG. 4 shows the contractor management platform 106 divided into respective capability areas 402. The contractor management platform 106 includes a health services contracting sub-platform 420, a contract information management sub-platform 422, an administration contracting sub-platform 424, and a contractor support sub-platform 426.

FIG. 5 shows the program integrity management platform 108 divided into respective capability areas 502. The program integrity management platform 108 includes an identify candidate case sub-platform 520, a manage case sub-platform 522, and a payment integrity sub-platform 524.

FIG. 6 shows the business relationship management platform 110 divided into respective capability areas 602. The business relationship management platform 110 includes an establish business relationship sub-platform 620, a manage business relationship sub-platform 622, a manage business relationship communication sub-platform 624, a terminate business relationship sub-platform 626, and a determine strategic alliances sub-platform 628.

FIG. 7 shows the provider management platform 112 divided into respective capability areas 702. The provider management platform 112 includes a provider enrollment sub-platform 720, a provider information management sub-platform 722, a provider support sub-platform 724, and a provider network management strategy sub-platform 726.

FIG. 8 shows the member management platform 114 divided into respective capability areas 802. The member management platform 114 includes an eligibility determination sub-platform 820, an enrollment sub-platform 822, a member information management sub-platform 824, a prospective and current member support sub-platform 826, and a market products and services sub-platform 828.

FIG. 9 shows the operations management platform 116 divided into respective capability areas 902. The operations management platform 116 includes a service authorization sub-platform 920, a member payment information sub-platform 922, a claims-encounters adjudications sub-platform 924, a cost avoidance sub-platform 926, a cost recoveries sub-platform 928, a payment and reporting sub-platform 930, a payment information management sub-platform 932, and a capitation and premium preparation sub-platform 934.

FIG. 10 shows the enterprise platform 118 divided into respective capability areas 1002. The enterprise platform 118 includes a health informatics sub-platform 1020, a procurement management sub-platform 1022, a privacy and compliance management sub-platform 1024, a legal management sub-platform 1026, a human resources sub-platform 1028, an information technology operations sub-platform 1030, and a facilities management sub-platform 1032.

The tables provided in the appendix immediately following the abstract, which form part of this disclosure, provide an explanation of the capabilities and corresponding key assessment areas and performance criteria for some of the capabilities within the respective sub-platforms. Each capability may include one or more key assessment areas. Each key assessment area may include one or more additional key assessment areas. In other words, a business capability may include sub-capabilities, and therefore, key assessment areas corresponding to the multiple sub-capabilities. The tables in the appendix show specific criteria used to analyze each capability.

FIG. 11 shows a multidimensional Medicaid program performance reference set 1100 (“reference set 1100”) that provides a capability detail pool from which the system described below may obtain benchmarking tables for a Medicaid program. The reference set 1100 includes multiple key assessment performance reference tables (“reference tables”), two of which are labeled 1102 and 1104. Each reference table may provide the benchmarking criteria for a specific capability, such as those noted above with respect to FIGS. 2-10.

One dimension of each table may establish the ‘Basic’ performance level 140 specifying ‘Basic’ performance assessment criteria, the ‘Competitive’ performance level 142 specifying ‘Competitive’ performance assessment criteria, and the ‘Market Leading’ performance level 144 specifying ‘Market Leading’ performance assessment criteria. Another dimension of each table may specify one or more key assessment areas (KAAs), several of which are labeled 1106, 1108, and 1110. As noted above, performance criteria, e.g., the PCC 1112, populate each key assessment performance reference table to provide benchmark criteria for ‘Basic,’ ‘Competitive,’ and ‘Market Leading’ characteristics.

The reference set 1100 represents the HPCA model 100. Consistent with the HPCA model 100, the reference set 1100 may organize multiple reference tables into a hierarchical structure defining discrete changes in granularity. In one implementation, the hierarchical structure includes reference tables, high-level platforms, platforms, sub-platforms, and models. FIG. 11 labels three sub-platforms 1114, 1116, and 1118. The reference set 1100 may further organize the platforms, two of which are labeled 1120 and 1122. Platforms aggregate into the HPCA model 100 and corresponding reference set 1100. Additional, different, or fewer levels of granularity may be defined in the HPCA model 100.

The reference set 1100 may dynamically populate the reference tables with the most up-to-date performance criteria, for example upon retrieval and presentation by a business analysis consultant. The performance criteria may be retrieved from a performance capability criteria database or other information source.

FIG. 11 also shows an example of a database implementation 1124 of a portion of a reference table. In particular, the database implementation 1124 includes records (e.g., the records 1126, 1128, 1130) that establish each PCC 1112. In the example shown, each record includes a PCC field 1132, a category specifier field 1134, and a KAA specifier field 1136. Other fields may be provided, such as a reference table assignment field or reference set assignment field. The records categorize each PCC into a specific category (e.g., ‘Basic’), into a specific KAA, and, optionally, into a specific reference table in a specific reference set for any particular HPCA model.

FIG. 12 shows a high-performance capability assessment system (“system”) 1200. The system 1200 includes a processor 1202 and a memory 1204. Several databases support the operation of the system 1200, including a performance capability database 1206, a performance measured database 1208, a capability detail pool database 1210, and an assessment results database 1226. The system 1200 may include a local display 1212 and input/output interfaces 1217 (e.g., including a keyboard, mouse, microphone, speakers, or other device), and, through the communication interface 1214 and networks 1216, may communicate with remote devices 1218 and remote displays 1220. The networks 1216 may be any combination of external networks (e.g., the Internet) and internal networks (e.g., corporate LANs). The displays 1212 and 1220 may, for example, present performance capability assessment models 1222 that the system 1200 retrieves from the capability detail pool database 1210 for review, modification, and application by process engineers or other individuals. With regard to local access or access by the remote devices 1218, the system 1200 may include a login processing program 1224 to authenticate and/or authorize access to the system 1200. To that end, the login processing program 1224 may include username/password verification, private/public key encryption, or other validation and data protection capabilities.

In one implementation, the capability performance database 1206 stores performance criteria. As will be described in more detail below, the system 1200 may populate performance capability assessment models with performance capability criteria suited to any particular platform or sub-platform (e.g., a program quality management sub-platform 220) and business capability at one or more capability levels across one or more key assessment areas. The performance measured database 1208 may store the determined, measured, or otherwise ascertained characteristics, criteria, and other measured data of a particular key assessment area as representative practice data 1248. The representative practice data 1248 may be obtained through interviews with business consultants and industrial engineers, through online questionnaires, through manual or automated analysis of business data (e.g., year-end operating reports), or by other means. The capability detail pool database 1210 stores the capability detail pool 1100, which includes pre-defined performance capability assessment models 1222. The assessment results database 1226 stores determined capability levels for specific capabilities that have been analyzed.

The system 1200 facilitates the review, modification, creation, and application of performance capability assessment models. In that role, performance capability assessment model manipulation logic (“manipulation logic”) 1246 within the system 1200 creates, retrieves, and stores capability assessment data 1228 in the memory 1204. The manipulation logic 1246 may establish capability assessment data 1228 in the memory 1204, including a capability assessment data structure 1230 with multiple capability levels (“CL”) 1232 organized along a scale of mastery dimension, multiple key assessment areas (“KAA”) 1234 organized along a key factor dimension, and performance criteria (“PCC”) 1236 that populate the performance capability assessment model 1230. The manipulation logic 1246 may vary widely in implementation, and, as one example, may include data storage logic 1252 that saves data in memory and user interface logic that accepts capability level specifications, key assessment area specifications, and performance capability criteria inputs to create new performance capability assessment models, to modify existing performance capability assessment models, to delete performance capability assessment models, or to retrieve performance capability assessment models for review.

In one implementation, the manipulation logic 1246 establishes the capability assessment data structure 1230 to include a multidimensional Medicaid program performance reference set that includes multiple key assessment performance reference tables in which the key assessment performance reference tables include a ‘Basic’ capability performance level, a ‘Competitive’ capability performance level, and a ‘Market Leading’ capability performance level.

The capability assessment data 1228 may also include a capability position specifier 1238. The capability position specifier 1238 may record the capability level along the scale of mastery 146, as determined for any particular capability. Thus, the system 1200 may store the performance level in the assessment results database 1226 or elsewhere for future retrieval and review.

In one implementation, the data population logic 1240 may be a data population program executed by the processor 1202 that populates template performance capability assessment models. For example, the data population logic 1240 may include input logic 1250 that accepts input specifying a capability of interest that indicates a particular performance capability assessment model. The data population logic 1240 may include query logic 1245 that executes database queries and prompts a user for input to obtain the corresponding performance capability criteria for the capability of interest.

In another implementation, for example, the query logic 1245 may receive an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis. The query logic 1245 searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table.

The data population logic 1240 may further include storage logic that adds the retrieved performance capability criteria to the template performance capability assessment model. The data population logic 1240 produces populated performance capability assessment structures 1242 that may be stored in the capability detail pool database 1210.

In addition to the analysis process described above, the system 1200 may provide an automated analysis of representative practice data 1248 that identifies relevant performance capability criteria and determines the position on the scale of mastery 146 of each key assessment area corresponding to the performance capability criteria for the representative practice data 1248. As one example, the system 1200 may implement capability assessment logic 1244 that includes comparison and/or matching logic that analyzes the representative practice data 1248 with respect to performance capability criteria to locate key assessment areas for which the system 1200 can determine capability levels to obtain a resultant performance level for each key assessment area.

Furthermore, the capability assessment logic 1244 may determine an overall position on the scale of mastery 146 as the capability position specifier 1238 for a capability under examination given the knowledge of where the key assessment areas corresponding to the capability under examination fall in each capability level. Thus, for example, the capability assessment logic 1244 may determine an overall capability level for a capability corresponding to the capability level for the majority of the key assessment areas, or it may apply a weighted analysis technique to give more emphasis to some key assessment areas than others in determining the overall position on the scale of mastery 146 for a capability. As another example, the capability assessment logic 1244 may implement an expert system (e.g., based on a neural network trained on prior determinations) that analyzes the determined characteristics with respect to the performance capability criteria and ascertains where the capability under examination falls along the scale of mastery 146 for each of the key assessment areas, or overall on the scale of mastery.

FIG. 13 shows a flow diagram 1300 for creating performance capability assessment models. The performance capability assessment model creator (e.g., the manipulation logic 1246) establishes a key factor dimension for the performance capability assessment model (1302). The performance capability assessment model creator also establishes a capability scale dimension for the performance capability assessment model (1304). The capability scale dimension may define a scale of increasing organizational capability. For example, the structure creator may create the ‘Basic’ level 140, the ‘Competitive’ level 142, and the ‘Market Leading’ level 144. The performance capability assessment model creator also populates the performance capability assessment model with capability performance criteria (1306). A capability detail pool 1100 may be formed to hold multiple tailored key assessment performance reference tables (1308). The performance capability assessment model creator may store the populated assessment structure in the capability detail pool for subsequent retrieval and analysis (1310).

FIG. 14 shows a flow diagram 1400 for retrieving and applying performance capability assessment models. A selection of a capability to be analyzed is obtained (1402). In one implementation, the system 1200 receives input data that specifies a Medicaid program area and a Medicaid program key assessment area for analysis. For example, the system 1200 may accept input from a business consultant that specifies a capability for analysis. The system 1200 may query the capability detail pool 1100 for a corresponding performance capability assessment model (1404). The corresponding performance capability assessment model may be pre-defined in the capability detail pool 1100, or the data population logic 1240 (or other actor) may populate a performance capability assessment model template that the system 1200 newly creates, or that the system 1200 retrieves from a data store, such as the capability detail pool database 1210.

In another example, the system 1200 searches the multidimensional Medicaid program performance reference set in the capability detail pool 1100 for a matching key assessment performance reference table based on the input data that specifies a Medicaid program platform and a Medicaid program key assessment area. The system 1200 retrieves the matching key assessment performance reference table and initiates analysis of the matching key assessment performance reference table to obtain a resultant performance level for the Medicaid program key assessment area.

The system 1200 obtains representative practice data 1248 for the capability under examination in the specific business under review (1406). For example, a business consultant may interview the business to determine how the business currently executes the capability under review. As another example, a representative from the business may complete a questionnaire, submit business data for analysis and parameter extraction, or otherwise provide the characteristics of their current capability execution. As a further example, the system 1200 may retrieve the representative practice data 1248 from a database of previously obtained representative practice data.

The system 1200 compares the representative practice data 1248 to the performance criteria in the performance capability assessment model (1408). For example, a business consultant may use his or her expertise to determine the level for the business and the capability under examination (1410). Alternatively or additionally, the capability assessment logic 1244 may perform an automated analysis of the assessment results data in the assessment results database 1226 and ascertain the performance level on the scale of mastery 146. The system 1200 may store the assessment results, including the determined performance level, for future reference in the assessment results database 1226 or other location (1412).

FIG. 15 shows a flow diagram 1500 for analyzing representative practice data 1248 to determine a Medicaid program and a Medicaid program assessment area to which the representative practice data applies. The system 1200 receives representative practice data 1248 as input data (1502). The system 1200 may receive the representative practice data 1248 from a database query performed by the query logic 1245 that the query logic executes periodically, when instructed by an operator, and/or automatically against any number of available database sources that store representative practice data 1248. The capability assessment logic 1244 analyzes the representative practice data 1248 to identify performance capability criteria in the capability detail pool 1100 that the capability assessment logic 1244 determines relevant to the representative practice data 1248 (1504). For example, the capability assessment logic 1244 may compare and/or match the content of the representative practice data 1248 with the performance capability criteria by using natural language processing (NLP), text string, and/or substring matching, by comparing tags linked to the representative practice data 1248 and that specify that any portion of the representative practice data 1248 is applicable to a specific PCC, by querying for a manual classification of the representative practice data 1248 to a PCC, or by using other matching techniques. The capability assessment logic 1244 may score and/or weight a performance capability criteria and compare the score and/or weight to a user specified relevance threshold to rank the relevance of the performance capability criteria to the representative practice data 1248 (1506). The user may specify particular terms and/or phrases to search and match between the performance capability criteria and the representative practice data 1248, in order to score the performance capability criteria.

The capability assessment logic 1244 may determine, based on the number of performance capability criteria that meet or exceed the relevance threshold, that the capability assessment logic 1244 has identified a sufficient number of performance capability criteria for a specific key assessment area in order to determine a performance level for the capability as a whole or any key assessment area within the capability (1508). As one example, where at least 51% of the performance capability criteria for a particular key assessment area meet or exceed the relevance threshold, the capability assessment logic 1244 applies the performance capability criteria to the representative practice data 1248. In another example, the performance capability criteria for a particular key assessment area may be ranked in importance and/or designated as mandatory in order to assess the key assessment area. In the event the capability assessment logic 1244 identifies the mandatory performance capability criteria for a key assessment area, the capability assessment logic 1244 applies the performance capability criteria to the representative practice data 1248.

The capability assessment logic 1244 may apply the performance capability criteria meeting or exceeding the relevance threshold to the representative practice data 1248 to determine whether any particular PCC is met. Accordingly, as the capability assessment logic 1244 analyzes the PCC, the system 1200 tracks the best fit of the representative practice data 1248 to the PCCs in the key assessment performance reference tables. In other words, the system 1200 determines how the representative practice data 1248 meets (or does not meet) each PCC, thereby gaining insight into whether the representative practice data 1248 is indicative of ‘Basic,’ ‘Competitive,’ or ‘Market Leading’ practices.

The system 1200 may also gauge the position on the scale of mastery 146 of each key assessment area corresponding to the performance capability criteria (1510). The capability assessment logic 1244 may further determine an overall position on the scale of mastery 146 for a capability (1512). The capability assessment logic 1244 may establish that a desired number and/or designated mandatory performance capability criteria for the key assessment areas have been identified as relevant to a capability and sufficient to determine the position on the scale of mastery 146 for the capability. For example, the capability assessment logic 1244 may determine an overall performance level for the capability based on the performance level determined for the majority of the key assessment areas. The capability assessment logic 1244 may apply a weighted analysis technique to give more emphasis to some key assessment areas than others in determining the overall position on the scale of mastery 146 for the capability. Although selected aspects, features, or components of the implementations are depicted as being stored in computer-readable memories (e.g., as computer-executable instructions or performance capability assessment models), all or part of the systems and structures may be stored on, distributed across, or read from other computer-readable media. The computer-readable media may include, for example, secondary storage devices such as hard disks, floppy disks, and CD-ROMs; a signal, such as a signal received from a network or received at an antenna; or other forms of memory, including ROM or RAM, either currently known or later developed.

Various implementations of the system 1200 may include additional or different components. A processor may be implemented as a microprocessor, a microcontroller, a DSP, an application specific integrated circuit (ASIC), discrete logic, or a combination of other types of circuits or logic. Similarly, memories may be DRAM, SRAM, Flash, or any other type of memory. The processing capability of the system may be distributed among multiple system components, such as among multiple processors and memories, optionally including multiple distributed processing systems. Parameters, databases, and other data structures may be separately stored and managed, may be incorporated into a single memory or database, may be logically and physically organized in many different ways, and may be implemented in many ways, including data structures such as linked lists, hash tables, or implicit storage mechanisms. Programs may be combined or split among multiple programs, or distributed across several memories and processors.

The logic, circuitry, and processing described above may be encoded or stored in a machine-readable or computer-readable medium such as a compact disc read only memory (CDROM), magnetic or optical disk, flash memory, random access memory (RAM) or read only memory (ROM), erasable programmable read only memory (EPROM) or other machine-readable medium such as, for example, instructions for execution by a processor, controller, or other processing device.

The medium may be implemented as any device that contains, stores, communicates, propagates, or transports executable instructions for use by or in connection with an instruction executable system, apparatus, or device. Alternatively or additionally, the logic may be implemented as analog or digital logic using hardware, such as one or more integrated circuits, or one or more processors executing instructions; or in software in an application programming interface (API) or in a Dynamic Link Library (DLL), functions available in a shared memory or defined as local or remote procedure cells; or as a combination of hardware and software.

In other implementations, the logic may be represented in a signal or a propagated-signal medium. For example, the instructions that implement the logic of any given program may take the form of an electronic, magnetic, optical, electromagnetic, infrared, or other type of signal. The systems described above may receive such a signal at a communication interface, such as an optical fiber interface, antenna, or other analog or digital signal interface, recover the instructions from the signal, store them in a machine-readable memory, and/or execute them with a processor.

The systems may include additional or different logic and may be implemented in many different ways. A processor may be implemented as a controller, microprocessor, microcontroller, application specific integrated circuit (ASIC), discrete logic, or a combination of other types of circuits or logic. Similarly, memories may be DRAM, SRAM, Flash, or other types of memory. Parameters (e.g., conditions and thresholds) and other data structures may be separately stored and managed, may be incorporated into a single memory or database, or may be logically and physically organized in many different ways. Programs and instructions may be parts of a single program, separate programs, or distributed across several memories and processors.

The HPCA 100 model provides unexpectedly good results for a performance capability assessment model, particularly in the Medicaid program area. In particular, the combinations of key assessment areas and particular assessment criteria of the HPCA model, including the criteria noted in the Appendix of Tables, provide significant advantages over other assessment models. The unexpectedly good results include clearly identifying and delineating from among multiple related complex processes the specific processes to improve, how to improve the process, and identifying concrete and measurable improvement goals.

While various embodiments of the invention have been described, it will be apparent to those of ordinary skill in the art that many more embodiments and implementations are possible within the scope of the invention. Accordingly, the invention is not to be restricted except in light of the attached claims and their equivalents.

TABLE 1 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Quality Management Capability: Manage Business Performance Basic Competitive Market Leading 1.5.3.1 Manage Productivity, Capacity & Cost 1.5.3.2 Manage Knowledge, Processes & Best Practices 1.5.3.3 Manage Service Quality

TABLE 2 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Quality Management Capability: Manage Quality, Risk, and Performance Market Basic Competitive Leading 1.5.4.1 Define Approach and Program 1.5.4.2 Establish Metrics and Indicators 1.5.4.3 Collect and Analyze Information 1.5.4.4 Provide Feedback and Change Practices as Appropriate

TABLE 3 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Cost Containment Capability: Perform Cost Containment Functions Market Basic Competetive Leading 1.9.1.1 Perform ongoing research and analysis to identify possible areas for cost containment. 1.9.1.2 Identify methods to reduce program administrative at health care costs 1.9.1.3 Review options, estimate of benefits, impact assessments, and alternatives 1.9.1.4 Prioritize initiatives 1.9.1.5 Implement approved cost reduction initiatives 1.9.1.6 Determine measurement methodology and benchmarks. 1.9.1.7 Continually measure and analyze cost reduction measures. 1.9.1.8 Provide reports on effectiveness of cost reduction measures

TABLE 4 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Administration Capability: Develop Agency Goals and Initiatives Basic Competitive Market Leading Agency receives notices that a review of current More in depth review of Agency Goals and Basic review of Agency Goals and goals and objectives is warranted. Objectives takes place. Objectives takes place Basic review of Agency Goals and Consensus on changes is established with Consensus on changes is established with Objectives takes place. stakeholders stakeholders Consensus on changes is established with Publish new statement of goals and objectives is Publish new statement of goals and objectives is stakeholders. published, including electronic forms published Publish new statement of goals and objectives is of publication. published.

TABLE 5 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Administration Capability: Develop and Maintain Program Policy Basic Competetive Market Leading Requests to add, delete, or change policy Requests to add, delete, or change policy Basic review of Agency Goals and Objectives are handled through a manual process. are handed through a combination of man- takes place Research staff are required to analyze policy ual/automated processes. Consensus on changes is established with and assess the impact of policy on budget, Few research staff are required to analyze stakeholders stakeholders, and other benefits. policy and assess the impact of policy on Publish new statement of goals and objectives Public hearings are held to explain existing budget, stakeholders, and other benefits. is published policy and policy changes.

TABLE 6 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Administration Capability: Maintain State Plan Basic Competitive Market Leading Notifications to review and update the state plan Notifications to review and update the state plan Even fewer staff is required to review the current are sent manually. are sent through an automated process. state plan, analyze changes to the state plan, and Additional staff is required to review the current Fewer staff is required to review the current research and assess impact of state plan changes. state plan, analyze changes to the state plan, and stateplan, analyze changes to the state plan, and research and assess impact of state plan changes. research and assess impact of state plan changes.

TABLE 7 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Administration Capability: Perform Organizational Planning Market Basic Competitive Leading 1.2.6.1 Conduct Environmental Analysis 1.2.6.2 Develop Strategic Plan 1.2.6.3 Develop Business and Tactical Plans 1.2.6.4 Develop Implementation Plans

TABLE 8 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Administration Capability: Market the Organization Market Basic Competitive Leading 1.2.1.1 Develop Marketing Plan 1.2.1.2 Develop Collateral Materials 1.2.1.3 Conduct Advertising 1.2.1.4 Conduct Public Relations 1.2.1.5 Manage Quality and Performance of the Marketing Process

TABLE 9 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Program Management Sub-Platform: Program Administration Capability: Provide Governance Market Basic Competitive Leading 1.2.5.1 Establish Mission, Value, and Direction 1.2.5.2 Develop and Operate the Governance Infrastructure 1.2.5.3 Formulate and Approve Organization Policies 1.2.5.4 Provide Oversight 1.2.5.5 Select and Evaluate Executive Management 1.2.5.6 Represent the Organization

TABLE 10 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Budget Formulate Budget Basic Competitive Market Leading Review of current budget takes place 1.3.1.2 Research and request information regarding revenue, costs, and benefits 1.3.1.3 Develop and discuss budget scenarios with stakeholders 1.3.1.4 Create, review, and approve new budget

TABLE 11 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Budget Manage F-MAP Basic Competitve Market Leading 1.3.3.1 Receive and review notification 1.3.3.2 Request, review, and analyze F-MAP, FFP, and applicable laws 1.3.3.3 Propose and submit change in approach to calculating F-MAP, FFP 1.3.3.4 Develop guidelines for change and implementation plan 1 .3.3.5 Develop algorithms 1.3.3.6 Publish newFFP rules

TABLE 12 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Budget Capability: Manage FFP for MMIS Basic Competitve Market Leading The Manage Federal Financial The Manage Federal Financial Participation business Improves on previous level capability plus: Participation business process is likely process increases its use of electronic interchange Virtual access to administrative and clinical primarily paper/phone/fax based and automated processes. records processing and some proprietary EDI. Agencies centralize common processes and are run Increased use of clinical data Timeliness of responses to inquiries as enterprises with “cost centers” responsible for Improves on previous level capability plus: and data reporting is indeterminate. meeting performance benchmarks. Focused data - data of record The agency has central point for developing Self adjusting business rules customer communications. Improves on previous level capability plus: Communications to customers are consistent, timely Use of clinical data to increase the accuracy of and appropriate. processes Improves on previous level capability plus by: Clinical staff focuses on exception cases Point-to-point or, wrapped connectivity to client- Improves on previous level capability plus: Point-to-point interfaces segregated by interface type Point-to-point collaboration Improves on previous level capability plus by. Content sensitive business logic Enhanced consistent timing for response to primary Improves on previous level capability plus: client Business Process Management Different interfaces with different data format and Metadata - Shared nationally semantics Improves on previous level capability plus: Improves on previous level capability plus by: Full interoperability other local, state, and Transactions are received and responded to via EDI, federal programs to provide complete virtual patient Web Portal clinical record and administrative data Business areas are structured functionally and not A business process collaborates with other by program/product line. processes in a peer2peer environment, eliminating Data is standardized for automated electronic redundant collection and interchange of data, and interchanges (interfaces) improving realtime, multi-axial processing. The Agency supports data and technology Members empowered to make own treatment integration end interoperability. decisions. Customers are able to access the information Most services instantly authorized or denied from required regardless of their entry point into the point of service; payment automaticallly established enterprise. without need of invoice.

TABLE 13 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Budget Capability: Manage State Funds Basic Competitive Market Leading A business process is likely primarily The Manage Federal Financial Participation Improves on previous level capability plus: paper/phone/fax based processing and some business process increases its use of Virtual access to administrative and clinical proprietary EDI. Programs are siloed so electronic interchange and automated records uncoordinated processes Improves on previous level capability plus: Non-standerdized data makes any type of Agencies centralize common processes and Increased use of clinical data cross program performance monitoring, are run as enterprises with “cost centers” Improves on previous level capability plus: management reporting, fraud detection, or responsible for meeting performance Focused data - data of record reporting and analysis difficult and costly. benchmarks Improves on previous level capability plus: Customers have difficulty accessing The agency has central point for developing Self-adjusting business rules consistent, quality, or complete information customer communications. Communications Improves on previous level capability plus: about programs, eligibility, services or to customers are consistent, timely and Use of clinical data to increase the accuracy, providers appropriate. of processes Communications are often not linguistically, Improves on previous level capability plus by: Improves on previous level capability plus: culturally or competency appropriate and Point-to-point or wrapped connectivity to Clinical staff focuses on exception cases socio-economic barriers to accessing client Improves on previous level capability plus: information and health care. Improves on previous level capability pus by: Point-to-point collaboration Programs create inconsistent rules across the Point-to-point interfaces segregated by Improves on previous level capability plus: Agency and apply their own rules interface type Content sensitive business logic inconsistently. Improves on previous level capability plus by: Improves on previous level capability plus: Indeterminate connectivity to client Enhanced consistent timing for responses to Business Process Management Programs create inconsistent rules across the primary client Improves on previous level capability plus: Agency and apply their own rules Improves on previous level capability plus by: Metadata - Shared nationally inconsistently. Different interfaces with different data format Improves on previous level capability plus: Programs create inconsistent rules across the and semantics Full interoperability with other local, state, Agency and apply their own rules Improves on previous level capability plus by: and federal programs to provide complete inconsistently. Transactions are received and responded to virtual patient clinical record and administrative Inconsistent timing for response to primary via EDI, Web Portal data client Business areas are structured functionally and Improves on previous level capability plus: Programs create inconsistent rules across the not by program/product line. Access to national clinical guidelines Agency and apply their own rules Data is standardized for automated electronic A business process collaborates with other inconsistently. interchanges (interfaces) processes in a peer2peer enviroment, Multiple data formats and semantics The Agency supports data and technology eliminating redundant collection and Programs create inconsistent rules across the integration and interoperability interchange of data, and improving realtime Agency and apply their own rules Customers are able to access the information multi-axial processing. inconsistently. required regardless of their entry point into the . . . External inputs & outputs are received/sent enterprise. Members empowered to make own treatment manually via paper, telephone, & fax decisions Transactions are individually reviewed using Most services instantly authorized or denied inconsistent interpretation of guidelines from point of service; payment automatically responded to via paper, USPS or fax. established without need of invoice.

TABLE 14 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Risk Capability: Manage and Issue Management Business Change Basic 1.7.1.1 Identify Business Case for Change 1.7.1.2 Assess Alignment with Strategic Direction 1.7.1.3 Define Change Program 1.7.1.4 Manage H/R Components of Transformation Staff and Manage Transformation Team Plan H/R Needs for Transformed Organization Manage Transformation Communications Manage Transformation Training Align Culture

TABLE 15 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Capability: Policy Management React to Changes in Law Basic 1.8.1.1 Review the Medicaid Plan amendment from the State as a result of a change in law 1.8.1.2. Assess impact of changes to the Medicaid program Cost cut the changes Identify the areas impacted 1.8.1.3 Submit impact of changes to CMS for approval

TABLE 16 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Receive State Policy Management and Federal Legislative Inquiries Basic 1.8.4.1 Capture types of inqiiries 1.8.4.2 Assess the inquiries/complaints for management to focus on

TABLE 17 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Respond to Policy Management CMS and GAO Audits Basic 1.8.3.1 Indicate agreement/disagreement with the findings 1.8.3.2 Indicate agreement/disagreement with CMS/GAO recommendations and monetary amounts, including costs questioned and other estimates 1.8.3.3 Identify target dates for completion of final action on recommendations with which management agrees. 1.8.3.4 Indicate agreement/disagreement with findings of reportable material weakness.

TABLE 18 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Work with the Policy Management Office of Government Affairs Basic 1.8.2.1 Identify program impact and record it 1.8.2.2 Identify policy impact and record it

TABLE 19 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Generate Financial Program Information and Program Analysis Report Basic Competitive Market Leading The Generate Financial & Program Analysis The business process increases its use of The business process interfaces with other Reports business process is likely done with a electronic interchange and automated processes via federated architectures or mix of tape, CD and some proprietary EDI. processes. Agencies are run as enterprises collaborates with other processes in a Programs are siloed so uniformity of data is with “cost centers” responsible for meeting peer2peer environment, eliminating redundant uncoordinated and non-standardized data performance benchmarks. collection and interchange of data, and makes any type of cross program performance Programs are agile and able to adjust their improving realtime, multi-axial processing monitoring, management reporting, fraud rules quickly when business activity monitoring detection, or reporting and analysis difficult and indicates that the rules are no longer yielding costly. desired benchmarks Agencies centralize and standardize data to increase its usefulness for performance monitoring, management reporting, fraud detection, and reporting and analysis. Business areas are structured functionaly and not by program/product line with infrastructure architected to support this design. Data is standardized for automated electronic interchanges (interfaces) Agency supports data and technology integration and interoperability.

TABLE 20 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Maintain Benefit/ Program Information Reference Information Basic Competitive Market Leading A business process is likely primarily A business process increases its use of paper/phone/fax based processing and some electronic interchange and automated A business process interfaces with other proprietary EDI. Programs are siloed so processes. Agencies centralize common processes via federated architectures or uncoordinated. processes and are run as enterprises with collaborates with other processes in a Non-standardized data makes any type of “cost centers” responsible for meeting peer2peer environment, eliminating redundant cross program performance monitoring, performance benchmarks. collection and interchange of data, and management reporting, fraud detection, or Centralization increases consistency of improving realtime, multi-axial processing reporting and analysis difficult and costly. communications. Agency business Clinical data is rarely the basis for decisions, relationships are increasingly hub and spoke and requires accessing paper medical records. vs. point to point with each internal and Most data is administrative use of encounter external party. data. Timeliness of responses to inquiries and These changes improve customers ability to data reporting is indeterminate. reliably access the information and services Customers have difficulty accessing they require. consistent, quality, or complete information Business areas are structured functionally and about programs, eligibility, services or not by program/product line with infrastructure providers. architected to support this design. Communications are often not linguistically, Data is standardized for automated electronic culturally or competency appropriate and interchanges (interfaces) that are oblivious to socio-economic barriers to accessing whether the sender or receiver is internal or information and health care. Programs create external, applying appropriate levels of security inconsistent rules across the Agency and to each request/receiver. apply their own rules inconsistently. . . . The Agency supports data and technology integration and interoperability.

TABLE 21 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Manage Program Information Program Information Basic Competitive Market Leading Data from enterprise information registries Records are processed using both manual and Records are sent through a fully automated or repositories is available to load automated processes, making the data easier to process. Records are processed manually, but the access. Even more sophisticated reporting, analysis, data is not made easily available. More sophisticated reporting, analysis, and and decision support capabilities are available. Basic reporting, analysis, and decision decision support capabilities are available. Data is archived in accordance with state and support capabilities are available. Data is archived in accordance with state record federal record retention requirements. Agency possesses record retention retention requirements. requirements.

TABLE 22 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Accounting Capability: Manage 1099s Basic Competitive Market Leading The Manage 1099s business process is likely The business process is increasing its use of primarily paper/phone/fax based processing and electronic interchange and automated processes. The business process interfaces with other some proprietary EDI. Programs are siloed and Agencies are completely centralized. Data is processes via federated architectures multiple 1099s may be created by different standardized for automated electronic interchanges or collaborates with other processes in a payment systems. (interfaces). peer2peer environment, eliminating redundant Timeliness of responses to inquiries and data Agencies are centralizing common processes to collection and interchange of data, and reporting is indeterminate. achieve economies of scale and increase improving realtime, multi-axial processing coordination. The Agency supports data and technology integration and interoperability. Centralization increases consistency of communications. Agency business relationships are increasingly hub and spoke vs. point to point with each internal and external party. The Agency actively supports and enables its customers to access information electronically.

TABLE 23 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Capability: Perform Accounting Accounting Functions Basic 1.4.2.1 Continuity Planning 1.4.2.2 General Ledger (includes Accounts Payable and Receivable) 1.4.2.3 Reporting 1.4.2.4 Account Maintenance

TABLE 24 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management - Develop and Maintain Medical and Network Policies Sub-Platform: Capability: Designate Approved Benefits Administration Service/Drug Formulary Basic Competitive Market Leading The Designate Approved Services/Drug The Designate Approved Services/Drug A business process interfaces with Formulary process is primarily a manuel process Formulary process is coordinated across other processes via federated architectures and may occur in silos without coordination. siloed systems, is centralized by the or collaborates with other Decisions are primarily based on fiscal impact and enterprise & is highly automated. processes in a peer2peer environment, regulatory requirements rather than clinical data. Review processes are centralized and eliminating redundant collection Notification to trading partners is not timely and standardized processes are emerging across and interchange of data, and improving is labor intensive accomplished primarily on systems, types of services and benefit packages. realtime, multi-axial processing. paper through use of provider mass mailings. Decisions are based on fiscal impacts and Communications to impacted members regulatory requirements, but increased use of are not linguistically, culturally or EDI increases accuracy of and access to competency appropriate and socio-economic clinical data to allow for analysis of health barriers to accessing information care outcomes as a determining factor. and health care are not addressed well. Agencies centralize provider notification and client communication functions requiring fewer staff and capitalizing on efficiencies. Communications to customers are consistent, timely and appropriate. The Agency actively supports and enables its customers to access information electronically.

TABLE 25 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Benefits Administration Capability: Develop and Maintain Benefit Package Basic Competitive Market Leading Benefit packages selections All programs introduce flexibility Services and providers are have pre-set services and within benefit packages, enabling selected within funding limits of provider types. Each eligible “consumer driven” health care benefit packages available to the may be offered only packages with more choices among member based on clinical and available via eligibility services and provider types socio-economic factors determination pathway taken. available within the funding limits of all benefit packages for which the member is eligible. Within each silo, eligible may Design of benefit packages is Services and providers are only be assigned to the best manual and is based on limited selected within member available package available paper-based access to external preferences such as health status, despite eligibility for more clinical data. desire to remain in the home, expansive services because what is culturally appropriate, systems may be limited to and functional competencies. supporting one eligibility span at a time. Design of benefit packages is automated with electronic access to electronic clinical data. Consumer-driven benefit packages are designed and updated real time based on collaborative interfaces with members' federated electronic health records.

TABLE 26 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Benefits Capability: Develop Administration Products and Services Basic Competitive Market Leading 1.1.4.1 Conduct Product Market Analysis and Define Segments 1.1.4.2 Position Product Concept Relative to Competition & Perform Concept Test 1.1.4.3 Design Products and Services 1.1.4.3.1 Develop Detailed Product Design 1.1.4.3.2 Build product infrastructure 1.1.4.4 Develop Product Pricing Strategy and Structure 1.1.4.5 Obtain Regulatory Approval 1.1.4.6 Perform Testing and Roll-Out 1.1.4.6.1 Pilot Project 1.1.4.6.2 Product Iteration 1.1.4.7 Launch Product 1.1.4.8 Manage Product and Segment Product Portfolio

TABLE 27 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Capability: Manage Actuarial Services Sub-Platform: Benefits and Medical Administration Economics Basic Competitive Market Leading 1.1.6.1 Manage Actuarial/Pricing Function 1.1.6.2 Manage Medical Economics 1.1.6.3 Manage External Reporting of Medical Cost & Quality Metrics

TABLE 28 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Sub-Platform: Benefits Administration Capability: Manage Rate Setting Basic Competitive Market Leading Notifications of rate Automated notifications of rate Rate changes changes are largely a changes. can be applied manual process. nationally. Research staff Fewer research staff required to required to conduct rate analysis for rate conduct rate analysis changes. for rate changes Rate updates are Automated rate updates manually applied Automated validation process for validating rates. Institutional services use the annual DRG Rate Setting Process to determine the Base Standard Dollar Amount (SDA) and DRG weight information for each State Fiscal Year. HHSC approves fee schedules for professional services according to set criteria for each provider type.

TABLE 29 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Program Management Capability: Sub-Platform: Benefits Sell Products Administration and Services Basic Competitive Market Leading 1.1.5.1 Determine and Implement Distribution Channels 1.1.5.2 Perform Sales to Consumers and Employers Generate Leads Create Proposals (for new & existing employers) Sell to New Employers Sell (Retail) to Consumers (new & existing) 1.1.5.3 Perform Underwriting and Develop Account-Specific Pricing and Financial Arrangements 1.1.5.4 Manage Quality and Performance of the Sales Process

TABLE 30 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Care Management Capability: Provide Access to Tailored Sub-Platform: Manage Medicaid Health Population Health and Wealth Messages Basic Competitive Market Leading Ensure that all client materials are accurate, appropriate, and written at a 4th to 6th grade reading comprehension level, with demonstrated comprehension by the Medicaid targeted populations. Ensure that all client materials are available in the languages of the population groups served. Ensure acceptable materials are available for the blind and visually impaired.

TABLE 31 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Care Management Capability: Manage Sub-Platform: Manage Case Medical Resource Use Basic Competitive Market Leading Perform Utilization Management Perform Prior Authorization Perform Concurrent Stay Review Perform Case Management and Disease Management Identification of member candidates Perform Case Management and Disease Management Perform Case Management a. Develop and implement case management services based on nationally recognized standards for all clients with chronic, complex, and acute medical conditions. Perform Case Management and Disease Management Perform Disease Management Perform Longitudinal case/care management (delivered by professional nurses involves following patients from the inpatient to the outpatient arena) Perform Case Management and Disease Management Perform Retrospective Review Manage outsourcing vendors Perform Case Management and Disease Management Coordinate with state agencies providing case management and other services. Evaluate the need for extension of services or alternative services when benefits cease or are exhausted. Perform Advanced Care Management Identification of member candidates Manage internal program Manage outsourcing vendors Internal or outsourced Perform Demand Management Manage Quality and Performance of the Medical Resource Use Process

TABLE 32 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Health Services Contracting Capability: Award Health Services Contract Basic Competitive Market Leading Indeterminate format for Application data are standardized External and internal validation proposal data nationally. All verifications can sources automatically send notice be automated. Rules are of change in contractor status. consistently applied. Much of the information is Contractors can submit National interoperability permits manually validated. applications via a portal. the enrollment process to send inquiries to any other agency, stale, federal, or other entities regarding the status of a contractor. Staff contact external and Decisions are uniform. Some Any data exchange partner can internal document verification manual steps may continue. send a notification regarding a sources via phone, fax. contractor enrolled with the state Medicaid program. Decisions may be inconsistent. Turnaround time can be Recertification notices are immediate. automatically generated. Requires large numbers of staff. Services created for the Clinical data is accessible by following steps and can be direct access. Manual steps only shared. required for exception handling. 1. Verify Credentials 2. Verify ID 3. Assign ID 4. Assign Rates 5. Negotiate Contract Decisions may take several days.

TABLE 33 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Health Services Contracting Capability: Close Out Health Services Contract Basic Competitive Market Leading At this level, the Close out At this level, the business process The business process Health Services Contract improves on the previous level incorporates the previous level business process has: capability by: capability plus: Indeterminate connectivity to Point-to-point or wrapped Virtual records client connectivity to client At this level, the Close out At this level, the business The business process Health Services Contract process improves on the previous incorporates the previous level business process has: level capability by: capability plus: Inconsistent timing for Point-to-point interfaces Use of clinical data response to primary client (trading partner agreements) segregated by interface type At this level, the Close out At this level, the business The business process Health Services Contract process improves on the previous incorporates the previous level business process has: level capability by: capability plus: Multiple data formats and Enhanced consistent timing for Focused data - data of record semantics response to primary client At this level, the Close out At this level, the business The business process Health Services Contract process improves on the previous incorporates the previous level business process has: level capability by: capability plus: External inputs & outputs are Different interfaces with Use of metadata received/sent manually via different data format and paper, telephone, & fax semantics At this level, the Close out At this level, the business The business process Health Services Contract process improves on the previous incorporates the previous level business process has: level capability by: capability plus: Transactions are individually Transactions are received and Self adjusting business rules reviewed using inconsistent responded to via EDI, Web Portal interpretation of guidelines responded to via paper/USPD or fax At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Virtual access to administrative Use of clinical data to increase and clinical records the accuracy of processes At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Increased use of clinical data Clinical staff focuses on exception cases. At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Focused data - data of record Point-to-point collaboration At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Use of metadata Content sensitive business logic At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Self adjusting business rules Business Process Management At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Use of clinical data to increase Metadata - Shared nationally the accuracy of processes At this level, the business The business process process improves on the previous incorporates the previous level level capability by: capability plus: Clinical staff focuses on Full interoperability with other exception cases local, state, and federal programs to provide complete virtual patient clinical record and administrative data At this level, the business Access to national clinical process improves on the previous guidelines level capability by: Members empowered to make own treatment decisions Use of electronic Claim The business process Attachment for Adjudication. incorporates the previous level capability plus: Most services instantly authorized or denied from point of service; payment automatically established without need of invoice Members empowered to make own treatment decisions.

TABLE 34 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Health Services Contracting Capability: Manage Health Services Contract Basic Competitive Market Leading At this level, the business The business process has almost The business process interfaces process is likely primarily eliminated its use of with other processes via paper/phone/fax based nonelectronic interchange and federated architectures and processing and some has automated most processes to collaborates with other processes proprieiary EDI. the extent feasible. in a peer2peer environment, eliminating redundant collection and interchange of data Timeliness of responses to Agencies centralize common At this level, the business process inquiries and data reporting processes to achieve economies interfaces with other processes indeterminate of scale. via federated architectures and collaborates with other processes in a peer2peer environment and improving real-time, multiaxial processing. Data is standardized for automated electronic interchanges Communications are consistent, timely and appropriate.

TABLE 35 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contract Management Capability: Inquire Sub-Platform: Contract Contractor Information Management Information Basic Competitive Market Leading 7.3.2.1 Receipt of contract verification information data set 7.3.2.2 Determine request status as initial or duplicate 7.3.2.3 Verify requestor authorization to receive requested information 7.3.2.4 Query contractor registry for requested information 7.3.2.5 Process and log response 7.3.2.6 Prepare response data set

TABLE 36 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contract Management Sub-Platform: Contract Capability: Manage Information Management Contractor Information Basic Competitive Market Leading Requests are received Requests are standardized from disparate sources in and automated. indeterminate formats. Validation is inconsistent Validation is consistent. and not rules-based. There are delays in Updates are timelier completing updates. Duplicate entries may go More automation of rules undetected. to maintain integrity of data repository. Irregular notification Change is immediately of change to users and available to users and processes that need processes that need to know. to know. Determinate interfaces (trigger event and results; messages to external entities), standardized data, consistent business rules and decisions, easy to change business logic. Manage Contractor Information is handled by a business service.

TABLE 37 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Administration Contracting Capability: Award Administrative Contract Basic Competitive Market Leading The business process uses The process uses application data At this level, the business process indeterminate formal for that is standardized nationally. interfaces with other processes application data via federated architectures and collaborates with other processes in a peer2peer environment, eliminating redundant collection and interchange of data Much of the information is All verifications can be At this level, the business process manually validated. automated. interfaces with other processes via federated architectures and collaborates with other processes in a peer2peer environment and improving real-time, multiaxial processing. Staff contact external and Rules are consistently applied. internal document verification sources via phone, fax. Decisions may be inconsistent. Contractors can submit applications via a portal. Requires large numbers of staff. Decisions are uniform. Some manual steps may continue Decisions may take several Turnaround time can be days. immediate Services created for the following steps and can be shared 1. Verify Credentials 2. Verify ID 3. Assign ID 4. Assign Rates 5. Negotiate Contract

TABLE 38 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Administration Contracting Capability: Close Out Administrative Contract Basic Competitive Market Leading At this level, the business The business process has almost At this level, the business process process uses indeterminate eliminated its use of interfaces with other processes connectivity to client. nonelectronic interchange and via federated architectures and uses application data that is collaborates with other processes standardized nationally. in a peer2peer environment, eliminating redundant collection and interchange of data Internal and external inputs and All verifications can be At this level, the business process outputs are received or sent automated. Rules are interfaces with other processes manually via paper, telephone consistently applied. via federated architectures and and fax. collaborates with other processes in a peer2peer environment and improving real-time, multiaxial processing. Decisions may be inconsistent. Decisions are uniform. Some manual steps may continue. Requires large numbers of staff. Turnaround time can be immediate. Inconsistent timing for response to primary client.

TABLE 39 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Administration Contracting Capability: Manage Administrative Contract Basic Competitive Market Leading The business process uses The process uses application data At this level, the business process indeterminate format for that is standardized nationally. interfaces with other processes application data via federated architectures and collaborates with other processes in a peer2peer environment, eliminating redundant collection and interchange of data Much of the information is All verifications can be At this level, the business process manually validated. automated. interfaces with other processes via federated architectures and collaborates with other processes in a peer2peer environment and improving real-time, multiaxial processing Staff contact external and Rules are consistently applied. internal document verification sources via phone, fax. Decisions may be inconsistent. Contractors can submit applications via a portal. Requires large numbers of staff. Decisions are uniform. Some manual steps may continue. Decisions may take several Turnaround time can be days. immediate. Services created for the following steps and can be shared. 1. Verify Credentials 2. Verify ID 3. Assign ID 4. Assign Rates 5. Negotiate Contract

TABLE 40 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Contractor Support Capability: Manage Contractor Communication Basic Competitive Market Leading The process is primarily At this level, the contractor There is support collaborative conducted via paper and phone. communications are primarily discernment of communication electronic, with paper used only needs of prospective and current secondarily. contractors via PHRs. Contractor communications are Communications are centralized Interoperability and data sharing likely uncoordinated among ensuring agencywide agreements among states will multiple, siloed programs and coordination and greater ability facilitate contractor not systematically triggered by to measure the efficacy of communications across state agency-wide processes; lacks provider communications lines. data to appropriately target contractors; may encounter obstacles to delivery. Responses may be untimely, Contractor registries use inconsistent and is labor standardized contact data, intensive. including NPS address standards, to alleviate postal delivery failures.

TABLE 41 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Contractor Support Capability: Perform Potential Contractor Outreach Basic Competitive Market Leading The process is primarily At this level, the process is The process may include conducted via paper and phone. primarily electronic, with paper automated targeting of providers used only secondarily. via RHIO, PHRs and EHRs based on analysis of performance and business activity monitoring. Outreach is centralized which Process may include ensures that current and collaborative discernment of prospective providers will be able individual contractor entities or to access information. organizations to whom outreach communications should be sent Access to standardized electronic based on indicator algorithms that clinical data via registries, trigger during business activity electronic prescribing, claims and monitoring at the agency. service review attachments and electronic health records, as well as use of GIS and socioeconomic indicators. Contractor registries use standardized contact data, including NPS address standards, to alleviate postal delivery failures.

TABLE 42 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Contractor Management Sub-Platform: Contractor Support Capability: Support Contractor Grievance and Appeal Basic Competitive Market Leading The process is entirely paper The process conducts much of its The process enables contractors based, which results in poor business electronically, except to file grievances and appeals in a document management and where paper documents are collaborative environment via process inefficiencies that required by law, which are PHRs and EHRs. impact timeliness. OCRM for electronic data capture. Grievances and appeals are Access to administrative data is Program Quality Management is filed, managed, and resolved by readily available and better able to apply performance siloed programs standardized. measures and focus business activity monitoring on operational data to detect opportunities for process, provider to alleviate issues that give rise to grievances and appeals Providers may have difficulty: Improved process timeliness, Program Quality Management is Finding the “Right Door” for document management, and better able to apply performance filing grievances and appeals supports business activity measures and focus business monitoring of performance activity monitoring on measures. operational data to detect opportunities for contractor improvements to alleviate issues that give rise to grievances and appeals. Providers may have difficulty: Clinical data is still paper-based Providers can access program Accessing program rules to and difficult to access in a timely rules to discern whether their discern the merit of their manner grievances or appeals have merit grievance or appeal Providers may have difficulty: The process is administered as Getting assistance on their part of the Medicaid enterprise. case or providing additional information Providers may have difficulty: Contractors can electronically Receiving consistent access program rules to discern responses or communications whether their grievances or that are linguistically, culturally appeals have merit. and competency appropriate Communications are consistent and timely. The process supports the Program Quality Management Business Area

TABLE 43 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Capability: Develop Enrollment and Manage Network Basic Competitive Market Leading 6.1.3.1 Develop & Maintain Network Composition/ Expansion Policy and Service Strategy 6.1.3.2 Recruit Providers 6.1.3.3 Credential and Re- Credential Providers 6.1.3.4 Contract with Providers 6.1.3.5 Develop & Maintain Contracting and Incentive Policies 6.1.3.6 Manage provider reimbursement program 6.1.3.7 Profile Providers 6.1.3.8 Manage and Monitor Provider 6.1.3.9 Manage Quality and Performance of the Network Management Process

TABLE 44 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Enrollment Capability: Disenroll Provider Basic Competitive Market Leading 6.1.2.1 Receive disenrollment request/information 6.1.2.2 Assign identifier for tracking and validate application syntax/semantic 6.1.2.3 Determine disenrollment request/ information status, verify disenrollment information, and validate against state rules 6.1.2.4 Produce disenrollment record in provider registry 6.1.2.5 Request preparation of disenrollment notification and appeal rights 6.1.2.6 Request provider outreach and send relevant state policy information 6.1.2.7 Alert operations and program management disenrollment information has been loaded into the provider registry

TABLE 45 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Enrollment Capability: Enroll Provider Basic Competitive Market Leading Provider enrollment staff meet Provider enrollment staff receive The enrollment process has access state and federal requirements and process paper and Web-based to all provider registries for processing applications applications adhering to state nationally via data sharing and timely and accurately. Medicaid agency specific interoperability agreements. standards. Staff receive and process paper Providers are enrolled timely and Messages are automatically sent enrollment applications and accurately with additional data to the special programs to manually apply the agency's that match provider to patient consider enrollment of providers business rules resulting in needs, identify provider business mapping to criteria. creating and maintaining a relationships, and support provider network that provides monitoring of delivery and quality access to benefits for eligible of care. members. Decisions on application may The majority of applications are All enrollment application take several days but \vithin automated and use MITA standard processes are automated; staff State regulations. interfaces for receipt of the only handle exceptions. application and the automated result messages Application data and format are Most verification and validation The National Health Information non standard. of application information are Network supports federated automated. Manual intervention registries that identify providers is required on an exception basis. across the country who are qualified to serve special populations or who are disqualified based on criminal activity. Some enrollment records are MITA standard interfaces are used Turnaround time is immediate, on stored electronically but storage to validate credentials and verify a national scale. is not centralized. or obtain ID numbers. Provider data, including ID and Other agencies within the state Medicaid Provider Registries are taxonomy, is not comparable collaborate with Medicaid to offer federated with regional data across provider types and a one-stop shop to the applicant by exchange networks across the programs, reducing ability to adopting the MITA standard country and if desired, monitor performance or detect interfaces. internationally. fraud and abuse. Staff contact external and There is a timely, robust, and Authorized, authenticated parties internal credentialing and coordinated provider network. have virtual, instant access to verification sources via phone, provider data, nationally. fax. A large staff is required to meet targets for manual enrollment of providers. Requires large numbers of staff. The NPI is the ID of record. Access to clinical data improves capability to select providers that meet quality standards. Much of the application Credentials are automatically re- Any daia exchange partner can information is manually validated and staff receive alerts send a notification regarding a validated. when adverse results occur. provider enrolled with any program in the U.S. Decisions may be inconsistent Through use of federated Nationally interoperable registries. Medicaid staff expands validation sources automatically its ability to identify providers send notice of change in provider with special qualifications status, eliminating the need to suitable for enrollment in reverify, supports detection of programs that serve special sanctioned providers in real time populations. anywhere in the U.S. Due to limited monitoring and Members interact directly with Full automation of the process re-verification of enrolled providers. plus access to national clinical providers' status, sanctioned data reduces staff requirements to providers may continue to be a core team of professionals who enrolled. monitor provider network performance. Focus on building a provider Cultural and linguistic indicators Prospective monitoring of network that meets needs of the improve selection of appropriate program integrity during members. providers. adjudication improves detection of fraud and abuse, resulting in timelier sanctioning Staff do not have time to focus Turnaround time on application Clinical data can be accessed, on cultural and linguistic decision can be immediate nationally, and monitored for compatibility, member measuring performance. satisfaction, or provider performance. Application data interfaces are Performance measures can be standardized nationally using shared via federated Provider MITA standards. Registries, nationally. Enrollment records are stored in Providers and care managers either a single Provider Registry access standardized National or federated Provider Registries Provider Registries and view that can be accessed by all clinical performance indicators to participants. make informed decisions re The NPI is the identifier of provider selection, provider record. referrals. Providers, members, and state enrollment staff have secure access to appropriate data on demand. Performance data is only periodically measured and requires sampling and statistical calculation. Enrollment processes continue to be handled by siloed programs according to program-specific rules. Providers can submit on paper and electronically via a portal which improves turnaround time, but most applications are submitted electronically. Verifications are a mix of manual and automated steps. Electronic applications adhere to MITA standard interface requirements. Medicaid and sister agencies collaborate on provider enrollment processes. Manual steps may continue only for exceptions. Process requires fewer staff and improves on results. Shared processes and inter-agency collaboration contribute to streamline the process. Automation of some business rules improves accuracy of validation and verification. The emphasis on managed care and waiver programs encourages more scrutiny of and reporting to national databases. All verifications can be automated and conducted via standardized interfaces. Consistent enrollment rules, standardized data available from a single source support continuous performance measures that can be used to adjust rates in real time. The agency sends verification inquiries to any other agency regarding the status of a provider. The quality of the provider network is improved. Guidelines ensure adequacy of network. Members are assigned to PCPs to coordinate their care. Members interact directly with provider and can view provider profiles and locations, make informed choices Cultural and linguistic indications improve selection of appropriate providers.

TABLE 46 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Capability: Manage Quality and Information Management Performance of HCD Processes Basic Competitive Market Leading Develop & Maintain Quality Policies Evaluate, Monitor & Collect Data for Required Metric Measurement Information Maintain & Prepare for Accreditation Develop & Monitor COMPLAINT, Concern, Appeals (CCA) Process Develop & Implement Quality Improvement Initiatives Monitor and Measure Performance and Quality Management Process

TABLE 47 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Information Management Capability: Inquire Provider Information Basic Competitive Market Leading Inquiries are received from Routine inquiries for provider Provider registry is federated with different sources to obtain information are standardized and RHIOs nationally so that any information about a provider in automated within the agency via stakeholder can request provider nonstandard formats. AVRS, Web portal, EDI information to the extent authorized anywhere in the country. Most requests are sent via Responses are immediate or Pointers to selected clinical telephone, fax, or USPS. within batch response parameters. information are added to the provider registry data Research is performed manually. Responses are consistent and Turnaround time is immediate, on timely a national scale. Responses are inconsistent and A reduced work force is required Information, including clinical, manual. to handle problems and direct can be shared among authorized telephone inquiries. entities within the state. There may be delays in MITA standard interfaces are used Medicaid Provider Registries are responses. for inquiries regarding provider federated with regional data registry information. exchange networks across the country and if desired, internationally. Complies with agency goals and Other agencies statewide can All authorized data exchange expectations. adopt MITA standard interfaces partners can access provider and participate in the inquiry information. process. Most requests for verification of NPI is the ID of record used in the Inquiries include summary provider information are inquiry regarding provider clinical information relating to received and responded to information provider performance and quality manually via phone, fax, USPS. of care. Information is researched Requests for provider information Automated access to information manually. There may be are automated via AVRS, Web nationally further improves inconsistencies in responses. portal, EDI within an agency efficiency. using agency standards for messages Staff research and respond to Responses are immediate. Regional and national, federated requests manually. provider registries eliminate redundant overhead, i.e., one-stop shop inquiries. Requires research staff. Information can be shared among Incorporation of clinical data, authorized entities within the nationally, improves accuracy of state. some responses. Responses are manually Automation improves access and Requesters benefit from access to validated. accuracy. national clinical data as an added value. Process complies with agency Access is via Web portal and EDI requirements. channels. Requesters receive the Data inquiry message use MITA information they need. standard interfaces, improving accuracy. Collaborating agencies using the MITA standard interfaces can exchange data on registered providers. Responses to requests to inquire about provider information are automated. Fewer staff required to support Provider information is continuously refreshed. One stop shop for agencies who share providers. Automation leads to fewer staff. Number of responses per day increases significantly. Use of MITA standard interfaces streamlines the inquiry process. Automation improves accuracy of responses. MITA standard interfaces produce consistent responses to inquiries. Requesters receive immediate responses. Requesters have a one-stop shop to access collaborating agencies to obtain information on a provider.

TABLE 48 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Information Management Capability: Manage Provider Information Basic Competitive Market Leading Changes to provider registry are Changes to provider registry are The agency's provider registry is managed manually. standardized within the agency federated with statewide RHIOs and automated. and is connected to all other RHIOs and registries nationally through the NHIN. Accuracy of data is manually Validation of changed data is Information and changes re a verified. There is no single consistent provider are shared by all entities standard for data stored for that contract with that provider different types of providers. Duplicate entries may go Updates are timely (within 24 Provider registry' information undetected. hours). includes performance measures automatically communicated from the provider's clinical record. Notification to users re changes Changes are immediately Turnaround time is immediate, on to registry is nonstandard. available to users and business a national scale processes that need to use this information. Needs of various users of MITA standard interfaces are Updates are available to all data provider data are uncoordinated used for changes to provider exchange partners. and may be unmet. registry. Manual and semi-automated Other agencies statewide can Medicaid Provider Registries are steps require some days to collaborate with Medicaid and federated with regional data complete update and accept the MITA standard exchange networks across the maintenance process. interface country and if desired, internationally Updates are made to data NPI is the ID of record and this Information is accessible to all manually. Inconsistencies and standard is used by all data exchange partners. Clinical inaccuracies can go undetected. downstream business processes. data is included in the data set. Staff perform the updates Provider updates are automated Updates are immediately posted manually. with date stamp and audit trail and accessible to all data exchange partners. Requires large data entry staff. Update can be immediate. Clinical data is used to trigger provider registry updates. Updates are manually validated. Data exchange partners receive Any data exchange partner can update information instantly. send a notification regarding a provider record update to any other program in the USA Process complies with agency Automated updates are consistent Nationally interoperable requirements. according to agency standards validation sources automatically send notice of change in provider status, eliminating the need to reverify. Provider update information is Dala conforms to M1TA standard Supports detection of sanctioned maintained and available to interfaces. providers in real time anywhere other business processes. in the USA. Provider records are stored in Can be expanded to any other either a single Provider Registry country to obtain information on or federated Provider Registries an immigrant or guest provider that can be accessed by all users of provider data Updates are automatically Full automation of the process processed. Edits are consistent. plus access to clinical data on a national scale reduces staff requirements to a core team of professionals who monitor provider network performance Regional, federated provider registries eliminate redundant overhead Updates are distributed to data Providers, members, and care sharing partners. One stop shop managers access standardized for entities who share providers. National Provider Registries and view clinical performance indicators to make informed decisions re provider selection, provider referrals. Fewer staff required to support. Distributed updates of changes to provider registry reduce start requirements. Automation improves accuracy or validation and verification of database updates. NPI is the ID of record and standardizes ID and taxonomy updates. In managed care and waiver settings, guidelines ensure adequacy of network Members are assigned to PCPs to coordinate their care. Automated maintenance of provider information ensures that timely, accurate data are available to support member assignment Members can view provider profiles and locations, make informed choices. Cultural and linguistic indicators improve selection of appropriate providers. Provider and member satisfaction improves because of speed and accuracy of enrollment process

TABLE 49 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Capability: Develop and Maintain Medical and Sub-Platform: Provider Support Network Policies Basic Competitive Market Leading 6.3.4.1 Develop and Maintain Contracting and Reimbursement Policies Define Standard Contracting Methodologies Define approved non-standard variations and rules for use 6.3.4.2 Develop and Maintain Medical Policies Define approved sources of external clinical information/ current practices Create external review & advice boards 6.3.4.2 Develop and Maintain Medical Policies Determine and monitor state/ federal requirements and impacts on medical policy and its application 6.3.4.3 Develop and Maintain Network Strategy and Plan

TABLE 50 Global Health and Life Sciences High Performance Capability Assessment Model Public Health Services - Medicaid Provider Management Capability: Sub-Platform: Provider Support Manage Pharmacy Basic Competitive Market Leading 6.3.5.1 Develop & Maintain Pharmacy Contracting Business terms NCPDP and code issues 6.3.5.2 Perform Pharmacy Prior Authorization 6.3.5.3 Perform Pharmacy Retrospective Review 6.3.5.4 Perform Pharmacy Credentialing 6.3.5.5 Manage Specially Pharmacy Contracting terms Prior Authorization

TABLE 51 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Support Capability: Manage Provider Communication Basic Competitive Market Leading Requests are received from Routine requests from providers Medicaid provider registry is providers in non-standard are standardized and automated federated with RHIOs on a formats. Most requests are sent within the agency via AVRS, Web national scale which enables the via telephone, fax, or USPS. portal, EDI. Medicaid agency to reach all targeted providers statewide to receive general communiqués or public health alerts. Research is performed manually. Research and response for these All health care agencies are able standardized communications are to collaborate in sending and immediate or within batch receiv ing communications response parameters. between agencies and among all Responses are inconsistent and Routine responses are consistent providers statewide. manual. There may be delays in and timely and require fewer staff. Many typical provider responses. communications are handled directly by connectivity between the provider's clinical record system and the Medicaid agency Complies with agency goals and The majority of communications Requests can be received and expectations. is automated. responded to nationally and internationally. Requires significant labor force. MITA standard interfaces are used Messages can be sent from one for automated messages between state Medicaid to providers in provider and agency other states depending on inter- agency agreements. Provider communication is not Provides a one-stop shop for Indicator algorithms can trigger coordinated among multiple, frequently asked questions for communication messages directly siloed programs and not Medicaid and other collaborating to the provider. systematically . . . agencies that accept the MITA standard interfaces. No emphasis on linguistic, Communications are standardized Inquiry and response, and cultural or competency-based within the Medicaid agency. communications sent by the considerations. agency are immediate. Turnaround time is immediate, on a national scale May encounter obstacles to Use of electronic communications Interaction between provider delivery. makes provision of appropriate clinical data and the agency is messages more feasible and cost- automatic. effective. Manual and semi-automated Provider registries use Medicaid Provider Registries are steps may require some days to standardized contact data, federated with regional data complete response. including NPI address standards, exchange networks across the to alleviate postal delivery country and if desired, failures. internationally. Responses are made manually Provider requests and responses Responses are standardized and and there may be inconsistency are automated via Web, AVRS, are immediately available. and inaccuracy (within agency EDI with dale stamp and audit tolerance level). trail. Staff research and respond to Inquiries and responses using The provider clinical record requests manually. MITA standard interfaces are information can trigger messages immediate. to and from the provider and the Medicaid agency. Requires large research staff. Automated response increase Access to clinical information can accuracy improve efficiency especially in alert messaging Responses are manually Access is via Web portal and EDI Automated access to information validated, e.g., call center audits; channels. nationally further improves provider satisfaction survey. efficiency. Process complies with agency requirements. Providers receive the Requests and responses are Full automation of the process information they need. standardized as MITA interfaces, plus access to national clinical improving accuracy. data reduces staff requirements to a core team of professionals who monitor provider satisfaction with responses to inquiries. Provider information is accessed Access to national clinical data via either a single Provider improves accuracy of targeted Registry' or federated Provider alerts. Registries. Provider information belonging to Some inquiries/responses are different entities can be virtually replaced by automated messaging, consolidated to form a single on a national scale. view. Responses to routine provider requests are automated. Fewer staff required to support. Information requested by provider is continuously refreshed Collaboration among agencies achieve a one-stop shop to provider inquiries. Automation leads to fewer staff. Number of responses per day increases significantly. Use of MITA standards and collaboration among agencies increases effectiveness. Automation improves accuracy of responses. MITA standard interfaces specify requests and response messages and are used by collaborating agencies in the state. Providers have no delay in obtaining responses. Providers have a one stop shop to access collaborating agencies to obtain information.

TABLE 52 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Support Capability: Manage Provider Grievance and Appeal Basic Competitive Market Leading This is an all-manual process. Grievance and appeal cases are Clinical data is automatically Grievances and appeals are filed filed via USPS and fax. accessed to substantiate case via fax and USPS. findings. Requests for documents are Documents are scanned and the Automated business rules that managed manually. case file is automated and can be include clinical data lead to earlier shared among case workers. resolution of cases. Confidential documents are Some review steps are automated The original case against a transferred by certified mail. using agency specific standards. provider may be triggered directly from the clinical record. Verification of information is Time required to develop the case Interoperability and data sharing handled manually is reduced. agreements across states facilitate case resolution. The process is lengthy There is more consistency in the Responses to research questions steps taken in the review and are immediate. resolution process. There may be inconsistencies MITA standard interfaces are used Turnaround time of information between cases of same type for Grievance and Appeal triggers gathering is immediate, on a and results national scale. This is an all-manual process. MITA standard interfaces are used Medicaid Provider Registries are Cases typically require months to initiate and develop the case. federated with regional data to complete. exchange networks across the country and if desired, internationally. Information is researched Case file is Web-enabled; All authorized data exchange manually information is shared among staff partners can access provider in managing the case. information, including clinical data. There may be inconsistencies in Medicaid collaborates with other Automated access to information responses. health and human service nationally further improves agencies that manage appea/s (o efficiency. create a one-stop shop model for both provider and consumer appeals. There are no standards for case Requests for provider information Automated business rules that data. are automated via AVRS, Web include clinical data lead to earlier portal. EDI within an agency resolution of cases Staff research and maintain Responses to research questions The original case against a manually. within the agency are immediate provider may be triggered directly across all data sharing partners from the clinical record. within the state. Process is labor-intensive. Over all timeline to resolve a case Full automation of the process is shortened. plus access to national clinical data reduce staff requirements to a core team of professionals who monitor stakeholder satisfaction with responsiveness to inquiries. Results take several months. Automation improves access and Regional and national, federated accuracy. provider registries eliminate redundant overhead. Terms of the settlement or Access is via Web portal and EDI Incorporation of national clinical results of the hearing are channels. data improves accuracy of final manually documented according disposition of the case. to the administrative rules of the state. There may be inconsistencies Agency standards for inquiries are Use of national clinical evidence between similar cases. introduced. reduces false positives and improves consistency of results. Process complies with agency Standard MITA interfaces requirements improve accuracy of content. Business process complies with Responses to requests to verify agency and state requirement for provider case information are a fair hearing and disposition. automated. Fewer staff required to support. MITA standard interfaces standards are used for creation of a case and publication of results. MITA standard interfaces are also used for inquiry and response to acquisition of information needed to build the case. Automation of some research steps reduces level of staffing required to manage a case. Collaboration with sister agencies that conduct appeals cases increases cost-effectiveness. Standardization of input and case results allows staff to focus on analytical activities. Automation is introduced into the case management process. Results are documented and recorded and can be accessed and retrieved as needed. MITA standard interface improves accuracy of case results. The provider and the agency benefit from introduction of automation to speed up the case resolution. Agencies benefit from introduction of MITA standard interfaces. Providers benefit from consistency and predictability of the process.

TABLE 53 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Provider Management Sub-Platform: Provider Support Capability: Perform Provider Outreach Basic Competitive Market Leading The business process is Increased use of agency standards Provider clinical information can primarily manual. for provider data improves trigger outreach and educational identification of targeted, enrolled material that are automatically providers; and aids in generated and sent to the identification of provider gaps. provider. Agencies use TV, radio, posters Electronic outreach and States can share provider for public transportation and educational materials are outreach and education materials community centers and clinics, available to providers via a Web with other states. and newspaper advertisements portal. to distribute outreach and educational information to targeted providers. Identification of targeted Standard educational and policy Triggers create messages from enrolled providers is based on information for enrolled providers provider clinical records that map provider registry data and is maintained electronically by to automated response messages claims history. the agency and is distributed to contained in an Outreach and the providers via electronic Education database. media Outreach is uncoordinated Automated translation and Turnaround time to identify target among multiple, siloed repositories of cultural and provide and transmit information programs. competency appropriate is immediate. statements makes provision of appropriate outreach material more feasible and cost-effective. Linguistic and cultural Use of GIS and socioeconomic Turnaround time for triggering, sensitivity refinements are indicators support targeting sending appropriate information absent. providers for outreach. is immediate, on a national scale. Quality and consistency of Provider registries, use CMS can send NPI and PDP outreach and education efforts standardized contact data, messages to all providers via are difficult to maintain. including NPI, to alleviate postal federated registries. delivery failures. The agency may encounter Outreach and education materials Medical Provider Registries are obstacles to delivery. are available via state Medicaid federated with regional data portal and are shared with other exchange networks across the collaborating agencies. country Outreach and education Electronic storage and Access to clinical data facilitates materials are manually prepared dissemination of provider manual identification of targeted and updated. materials shortens the time to providers and focuses the reach the provider. Non-routine outreach or education message. outreach is still timeconsuming. Provider manuals are constantly Outreach and education Access to clinical information revised and new pages are information are immediately improves efficiency by mailed to providers. available to providers across automatically mapping provider collaborating agencies. who needs assistance with generation of appropriate materials. Preparation of materials is Automation improves access and Automated business rules that clunky. accuracy include clinical data lead to faster identification of target list Information is subject to Access is via Web portal for Outreach and education can be inaccuracies and outreach material and via interoperable among states inconsistencies. electronic media for routine sharing business services. information distributed to enrolled providers. Staff develop and maintain Provider information is accessed Full automation of the process of materials manually. via federated Provider Registries identification of need plus access that can be accessed by all to clinical data reduces staff authorized entities within the requirements. state Effort is required to research Identification of targeted Regional, federated provider target provides population and providers and dissemination of registries eliminate redundant track mailings. information improve in accuracy. overhead in locating addresses Process is labor-intensive and Materials can be posted on a Web Outreach and education can be incurs postal expense. site for downloading by interoperable among states sharing providers. MITA standard interfaces Difficult to determine impact of Easier to identify target Incorporation of clinical data outreach and education. population and disseminate improves accuracy of appropriate information. identification or targeted providers and dissemination of appropriate messages. Studies are conducted to see if Automation reduces level of Access to provider information there are improvements in staffing required to perform on a regional or national basis. provider performance outreach and education. associated with outreach and education Business process complies with Easier to identify target Provider registries improve agency and state requirements population and disseminate accuracy of contact information. for educating the provider appropriate information. network regarding rules and regulations and how to communicate with the agency. Use of portal by provider is Outreach and education monitored to ensure that all are communications can be triggered actively engaged in downloading by automated messaging information. Easier to target provider populations and disseminate information appropriate to the needs. Agency can target providers who are not accessing information. Provider and agency benefit from introduction of automation to speed up the outreach and education process. Agencies benefit from sharing of information with other agencies. Providers benefit from consistency and timeliness of the information transmitted.

TABLE 54 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Eligibility Determination Capability; Determine Eligibility Basic Competitive Market Leading At this level, the business The business process benefits The business process has ease of process is designed to serve from member centric. No Wrong access to external sources of data, social services programs and Door initiatives and the including clinical data FFS Medicaid programs. technology support provided by SOA and rules-engines to meet the needs of programs besides FFS. The process is constrained by All programs introduce flexibility National interoperability permits FAMIS or state eligibility within benefit packages. the eligibility process to send system functionality. inquiries to any other agency, state, federal, or other entities in any part of the country. Indeterminate format for Application data are standardized. External and internal validation application data. All verifications can be sources automatical!)' send notice automated. Rules are consistently of change in member status. applied. Information is manually Decisions are uniform. Some Direct access to clinical data validated. manual steps may continue. improves the determination process. Manual validation steps only required for exception handling. Staff contact external and Requires fewer staff. Agency receives automated internal document verification notifications from the SSA and sources via phone, fax. other in-state and state and federal agencies with which it has data sharing agreements. Decisions may be inconsistent. Turnaround time can be Consumer-driven benefit immediate. packages are designed and updated real time based on collaborative interfaces with members' federated electronic health records. Requires large staff. Different types of eligibility pathways are merged into a single process. Decisions take several days. Spend-down is calculated automatically by the Calculate Spend-down process in the Operations Management, Member Payment business area. There are many pathways for Spend-down is treated as a determining eligibility. deductible that these eligibles must pay out-of-pocket before Medicaid will pay. When eligibility information is transferred from FAMIS to MMIS, it must be converted and data is lost. Benefit packages selections have pre-set services and provider types. Spend-down amounts are calculated manually. Member's record reflects whether spend-down amount is reached.

TABLE 55 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Capability: Sub-Platform: Enrollment Disenroll Member Basic Competitive Market Leading 9.2.1.1 Receive member eligibility termination request 9.2.1.2 Assign identifier and track processing status of eligibility termination and disenrollment request 9.3.1.3 Validate compliance of state application submission rules. 9.2.1.4 Verify demographic data and residence does not meet enrollment requirements 9.2.1.5 Create disenrollment data set to load disenrollment record into member registry 9.2.1.6 Alert applicant, provider, and contractor systems disenrollment information is loaded into member registry to prepare notifications 9.2.1.7 Prepare education materials for disenrollment reason in member outreach process 9.2.1.8 Alert operations, payment and billing systems of member disenrollment

TABLE 56 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Enrollment Capability: Enroll Member Basic Competitive Market Leading Enrollment processes are paper- Automated business rules Enrollment/eligibility based and siloed within facilitate design or seamless and determination processes are programs with no cross program coordinated package of quality. automated services triggered by coordination. point of service applications including PHRs and EHRs and run collaboratively. Stall makes decisions All verification of financial, If the provider's system is service autonomously and without socio-economic and health status enabled, it can prepopulate consultation with other information is automated and appropriate enrollment programs. some is real time. application(s) and to request additional information needed from the provider/applicant. Eligibility determination must Contractors and providers can The applicant is able to use online precede enrollment and is done query the registry to determine PHR or Web portal to fill out a separately. eligibility and program pre-populated application. enrollment Enrollment policies, procedures, Contractors may batch download Automated verification and benefits and application forms enrolled members rather than application response are real time. are program specific. receive theHIPAA834. Applicants must submit paper Process takes less time. Although Benefits are memberspecific, application forms to each data is electronic, some of the seamless and coordinated package program separately and reviewed verification of of quality. responses may take several information for waiver programs days. must be done manually. Process focus is on manually Turnaround time on application The Agency can automatically applying the agency's business decision can be immediate. query regional patient registries rules to ensure that enrollment for member enrollment meets state and federal information for verification and requirements. adjudication purposes such as COB Staff manually verifies financial, Medicaid and contractor member Agency receives automated socio-economic and health registries are updated in near real enrollment notifications from the status information. time as changes occur. SSA, EHRs, PHRs, intraand interstate sources and federal agencies. Enrollment in managed care and Managed care enrollment is rule Turnaround time is immediate, on waiver program requires driven and automated a national scale cumbersome extension of traditional fee-for-service processes. Benefits cannot be Enrollment application and Member registries are federated “blended” across programs. exchange data are standardized with regional data exchange nationally among Medicaids networks across the country and if improving access and accuracy. desired, internationally. Staff does not have the time or All programs use the HIPAA834 Agency automatically receives means to focus on meeting Enrollment transaction and standardized, timely and complete members' health, functions, implement a standard response enrollment data notifications cultural or linguistic needs. transaction from the contractors about members for verification for corrections. and adjudication purposes. Staff must send paper Enrollment records are stored in Authorized, authenticated parties enrollment notification to either a single member registry or have virtual, instant access to contractors. federated Agency member enrollment data, nationally. registries that can be accessed by all applications. Decisions on application may Member IDs are linked Any data exchange partner take several days, longer if algorithmically based on other nationally, and even verification of information is standardized data so that internationally, can query and difficult. enrollment records are receive appropriate data relating automatically linked across to an enrolled member programs. Contractors do not receive Providers, members and state Enrollment alerts to providers timely enrollment information. enrollment staff have secure reduces staff needed for access to appropriate and accurate enrollment outreach and data on demand verification of health status. Enrollment data and format are Performance data is only More effective enrollment data indeterminate. periodically measured and exchange because information requires sampling and statistical about all enrollment events of calculation. interest are pushed vs. querying potential sources of enrollment data. Enrollment applications are not Applications are only submitted Ability to auto/ad hoc query standardized and may still be electronically federated registries to access hard copy. enrollment and verification data increases data reliability and completeness, ensuring better process results. Some enrollment records are Medicaid centralizes all member “ . . . events of . . . ty and . . . stored electronically but storage enrollment processes, has a single [proce? ]ss results.” is not centralized. set of enrollment rules. ABOVE TEXT IS OBSCURED BY THE FOLLOWING TEXT IN A BOX OVERLAPPING IT: Medicaid centralizes all member enrollment processes; has a single set of enrollment rules. Member data is not comparable “Enrollments and verif . . . Applicants are “presumptively across programs reducing ability automated/* eligibili/ed/enrolled” to monitor program outcomes or ABOVE TEXT IS OBSCURED automatically at the point of care detect fraud and abuse. BY THE FOLLOWING TEXT based on national verification of Notifications to contractors are IN A BOX OVERLAPPING IT: health and socio-economic data, state-specific and differ by Medicaid centralizes all ensuring immediate access to contractor type. member enrollment processes; needed healthcare has a single set of enrollment rules. Notifications to contractors are Services created for the state-specific and differ by enrollment process can be shared contractor type. among states. Enrollment may occur in silos Process requires fewer staff and without coordination, i.e., improves on results. different processes and multiple pathways for each type of enrollment. Applicants and members can Shared services and inter-agency submit applications, make collaboration contribute to inquiries and choose providers streamline the process. and MCOs on paper. Staff contact external and Fewer applicants and members internal financial, are enrolled erroneously, reducing socioeconomic, demographic program costs. and health status verification sources via phone, fax. Requires a large staff to meet Automation of business rules targets for manual enrollment of improves accuracy of validation members. and verification. Siloed enrollment processes Automation of enrollment and result in redundant verification data interchange infrastructure, effort and costs. improves timeliness and quality of data. Much of the application Automated application of information is manually enrollment business rules validated and verification may improves consistency be difficult. Decisions may be inconsistent. Permits blending of program benefits to provide more appropriate services to members. Ineligible members may Synchronization of eligibility and continue to be enrolled due to enrollment processes ensures data limited monitoring and re- and decision consistency, thereby verification of enrolled member improving results. status. MMIS and Contractor member Automated enrollment registries frequently are not coordination of program benefits synchronized. improves the members' access to appropriate services and compliance with state/federal law. Focus is on accurately Members experience a seamless processing enrollment and and efficient eligibility/enrollment manually verifying information process no matter how or where as efficiently as possible. they contact the Agency. Staff does not have time to focus Members receive benefit on health, functional, cultural packages, specifically designed to and linguistic compatibility of meet individual's health, provider or program for the functional, cultural and linguistic member, or member satisfaction. needs.

TABLE 57 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Capability: Sub-Platform: Enrollment Perform Underwriting Basic Competitive Market Leading 9.2.3.1 Develop New Business Quote 9.2.3.2 Complete Underwriting Case Installation Tasks 9.2.3.3 Conduct Financial Account Management 9.2.3.4 Produce Customer Financial Reports 9.2.3.5 Develop Renewal Quote & Implement Sold Rates 9.2.3.6 Prepare Year-End Customer Settlement 9.2.3.7 Manage Underwriting Operations 9.2.3.8 Manage Underwriting Support

TABLE 58 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Member Information Management Capability: Inquire Member Eligibility Basic Competitive Market Leading Most requests for verification of Member eligibility/enrollment Turnaround time is immediate, on member information are verification is automated via a national scale. received and responded to AVRS, point of services devices, manually via phone, fax, USPS. Web portal, EDI, but remains siloed. Information is researched Responses can be immediate Information, including clinical, manually. There may be can be shared among authorized inconsistencies in responses. entities within theRHIO. Staff research and respond to Information can be shared among Medicaid Member Registries are requests manually. High rate of entities authorized by the Agency. federated with RHIOs. erroneous eligibility information. Verification takes effort and too Automation improves access and Medicaid Member Registries are much time for providers. accuracy. federated with regional data exchange networks across the country and if desired, internationally. Access is via AVRS, point of All authorized data exchange sen ice devices, Web portal, and partners can access member EDI channels. information Requires research staff. Increased use of HIPAA Mailing ID cards to members eligibility/enrollment data but not monthly is costly. the program and benefit data Access to clinical information can Verification is too expensive for Member eligibility/enrollment, improve efficiency for treatment, providers to use for each program, and benefit data and payment and operations. encounter but providers risk messaging formats adhere to Automated access to information cost of denied claims for MITA standard interfaces nationally further improves ineligible members and Member information is accessible I efficiency. noncovered services. from federated Member Full automation of the process Responses are manually Registries within the state plus access to clinical data validated. Enterprise. reduces staff requirements to a core team of professionals. Process complies with agency Responses to requests to verify Regional, federated provider requirements. member information are registries eliminate redundant automated. overhead. Requestors receive the Fewer staff required to support. Access to member information on information they need. Electronic verification is easier a national basis. and faster, so providers use it more often. Member information is Incorporation of clinical data, on continuously refreshed. a national scale, improves accuracy' of some responses. One stop shop for programs that Some inquiries/responses are share members. replaced by automated messaging, on a national scale, where authorized. Automation leads to few staff. Number of responses per day increases significantly. Electronic verification lowers cost to providers and reduces denied claims for ineligible members and non-covered services. Use of MITA standard interfaces increase cost-effectiveness. Because covered services are included in eligibility verification responses, providers experience fewer claim denials based on noncovered services. Automation improves accuracy of responses. Business services standardize requests and responses nationally More robust use of the HIPAA transactions increases accuracy-. Providers have no delay in obtaining responses. Providers have a one stop shop to access collaborating agencies to obtain information.

TABLE 59 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Member Information Management Capability: Manage Member Information Basic Competitive Market Leading The business process is Updates are automated with date At this level, the business process designed to serve FFS Medicaid stamp and audit trail; notification improves data availability and programs and meet MMIS to interested users and processes access for external users certification requirements such is immediate. nationally. as MARS and MSIS reporting. Data requests are received from Integration with FAMIS supports Member Registry accessed disparate sources in day based eligibility/enrollment. collaboratively by authorized data indeterminate formats. sharing partner applications nationally during shared business processes such as verifying COB. Data is shared in batch on a Member information is integrated Member information can be scheduled or ad hoc basis. via Member registry. shared across states Validation is inconsistent and Standard interfaces. Ability to access clinical data not rules-based. electronically to calculate performance and outcome measures. There are delays in completing Standardized data Turnaround time is immediate, on updates and loading member a national scale. data generated from multiple sources. Duplicate entries may go Consistent business rules and Updates are available to all undetected. decisions. authorized data exchange partners. Irregular update notification to Easy to change business logic. Medicaid Member Registries are interested users and processes. federated with regional data exchange networks across the country and if desired, internationally. Agencies may be limited to Manage Member Information is Updates notifications are monthly eligibility periods vs. handled by a business service. automatically sent to all day based authorized interested data eligibility/enrollment. exchange partners. Manual and semi-automated Member updates and data Any data exchange partner can steps delay updates, extractions can be immediate. send a notification regarding a maintenance processes and member record update to any require system down-time. other program in the USA. Inadequate audit trails. Data exchange partners receive Nationally interoperable update notifications instantly. validation sources automatically send notice of change in member enrollment and socioeconomic status in real time anywhere in the USA. Updates are made to individual Automated updates are made to Ability to access clinical data files manually. individual files and databases. electronically to calculate Databases may be relational. performance and outcome measures. Data issues duplicate Updates, notifications, and data Clinical data could be used to identifiers, discrepancies extractions are standardized. trigger member registry updates between data stores, and and to push member data to other information quality and applications. completeness. Staff must key new Member records are stored in Full automation of the process information, make updates either a single Member Registry plus access to clinical data on a manually, reconcile and or federated Member Registries national basis reduces staiT validate manually. that can be accessed by all requirements to a core team of authorized applications. professionals. Legacy systems limit Agency's Updates are distributed to data Regional, federated member ability to start and end sharing partners. One stop shop registries eliminate redundant eligibility in the MCOs within a for entities who share members. overhead. month. Requires numerous data entry Updates are automatically Using clinical data electronically staff to key new and updated processed. Edits are consistent. vs. paper charts lowers costs to information, and reconcile calculate performance and duplicates and data outcome measures. inconsistencies. IT staff needed to load member Fewer staff required to support. Automation and association of information generated from clinical data to member records other systems. improves accuracy of enrollment, performance measurement and care management processes. Updates and reconciliations MCO premiums are paid on a National access to member must be manually validated. daily rate, lowering capitation enrollment/clinical data improves premium costs for ineligible research, reporting, performance members. measures, outcome studies, care/disease management, and fraud detection. Process focus is on compliance Distributed update notifications Providers, members, and care with agency requirements and to federated member registries managers access standardized less on ensuing timely and automation reduces staff Member Registries on a national availability of quality/complete requirements scale to view clinical data needed data for users. for EHRs, PHRs, and care/disease management. Member information is Member data is associated Ability to access de-identified maintained and available to algorithmically to support member clinical data other business processes and federated access, automated electronically to calculate users. updates, reconciliation and performance and outcome extraction of complete and measures improves member and quality data regional patient care. Inquiries about members' Automation improves accuracy of Medicaid Member Registries are eligibility/enrollment are validation, verification, and federated with RHIOs nationally. received in non-standard reconciliation of data base formats. updates. Providers cannot be sure of the Automated maintenance of Providers can inquire about source from which to request member information ensures that member health records in other eligibility verification. timely, accurate data are available states. to support all processes needing member information Most requests are sent via Data Accessibility increases the Requests are expanded to include telephone, fax or point of efficiency, speed, and accuracy of inquiries re clinical information. service device. Media, data eligibility/enrollment and other format and content differ by processes. program. Providers often depend on The sources of eligibility Eligibility verification, program, paper member ID cards that can information are siloed within benefit, and Member Registry be inaccurate. different programs. health record locator services are integrated into applications. Newly eligible members must Routine inquiries for member wait to receive mailed ID cards information are automated. or the provider must verify Responses are immediate or eligibility by telephone within batch. Verification is performed MITA standard interfaces manually incorporate full HIPAAdata schemas. Responses are inconsistent, Member information is integrated sometimes incorrect, and via a Member Registry. untimely. Sister agencies adopt MITA standard interfaces to present a one-slop shop for inquiries regarding enrolled members.

TABLE 60 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Prospective and Capability: Current Member Support Manage Applicant and Member Communication Basic Competitive Market Leading Member communications are Member communications are Certain messages to member are primarily conducted via paper primarily electronic, with paper triggered by an individual's and phone. used only as needed to reach entries into personal health populations. records for prospective and current members. Member communications are Member communication is Member communications posted uncoordinated among multiple, organized around the “no wrong by an agency can be accessed by siloed programs and not door” concept. a member anywhere in the systematically triggered by country. agency-wide processes. Requests are received from Agencies support deployment of Information entered into provider members in non-standard internet access points to alleviate electronic health records can also formats. communications barriers. trigger specific messages to members regarding special programs and disease management information. Most requests are sent via Use of electronic Personal health records are telephone, fax, or USPS. communications makes provision available for free via the internet of appropriate member and accessible via kiosk and low communications more feasible cost telecommunication devices. and cost-effective. Research is performed Member Registries use Member Registry is federated manually. standardized contact data to with RHIOs. alleviate postal delivery failures. Responses are inconsistent and MITA standard interfaces are Public health alerts can be manual. used by Medicaid agency and triggered by clinical information collaborating sister agencies. in the patient's electronic health record. Routine requests from members Turnaround time is immediate, on There may be delays in are standardized and automated a national scale. responses. within the agencv via AVRS, Web portal, EDI Complies with agency goals and Research and response for these Member Registries are federated expectations. standardized communications are with regional data exchange immediate or within batch networks across the countrv and response parameters. if desired, internationally. Requires signification labor Responses are consistent and Responses are standardized and force. timely. can include clinical data Manual and semi-automated Requires fewer staff. Responses are standardized and steps may require some days to can include clinical data complete response. Responses are made manually Member requests and responses Responses are immediately and there may be inconsistency are automated via Web, AVRS, available. and inaccuracy (within agency EDI with data stamp and audit tolerance level). trail. Staff research and respond to Inquiries can be made to multiple Automated access to information requests manually. agencies via collaboration. nationally improves efficiency. Requires research staff. Response can be immediate . Full automation or the process plus access to clinical data, on a national scale, reduces staff requirements to a core team of professionals who monitor member satisfaction with responsiveness to inquiries. Responses are manually Automated responses increase Incorporation of clinical data, on validated accuracy. a national scale, improves accuracy of some responses Process complies with agency Access is via Web portal and EDI Some inquiries/responses are requirements channels. replaced by automated messaging on a national scale. Members receive the Requests and responses are information they needed standardized nationally, improving accuracy. Member information is accessed via either a single Member Registry or federated Member Registries. Member information belonging to different entities can be virtually consolidated to form a single view. Responses lo member requests are automated. Fewer staff required to support. Information requested by member is continuously refreshed. Collaboration among agencies achieves a one-stop shop for member inquiries. Automation leads to fewer staff. Number of responses per day- increases significantly. Collaboration and shared services increase cost effectiveness. Automation improves accuracy of responses. MITA standard interfaces improves requests and responses nationally. Members have no delay obtaining responses. Members have a one stop shop to access collaborating agencies to obtain information.

TABLE 61 Global Heallh and Life Sciences High Performance Capability- Assessment Model - Public Heallh Services - Medicaid Member Management Sub-Platform: Prospective and Capability: Manage Current Member Support Customer Relationships Basic Competitive Market Leading 9.4.4.1 Manage Quality and Performance of the Customer Relationship Management Process Handle Member Profile Calls Escalate & Follow-up on Inquiries Handle Misdirected Calls 9.4.4.2 Manage member relations

TABLE 62 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Prospective and Capability: Manage Member Current Member Support Grievance and Appeal Basic Competitive Market Leading 9.4.2.1 Receive grievance or appeal 9.4.2.2 Request additional documentation as appropriate 9.4.2.3 Determine grievance or appeal status (initial, second, or expedited) 9.4.2.4 Triage to appropriate personnel for review 9.4.2.5 Schedule and conduct hearing within required time 9.4.2.6 Determine disposition 9.4.2.7 Request preparation of a formal disposition to be sent to applicant member

TABLE 63 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Member Management Sub-Platform: Prospective and Capability: Current Member Support Perform Population and Member Outreach Basic Competitive Market Leading Business process is The business process is organized At this level, the business process uncoordinated among multiple, around the “no wrong door” is national in scope, based on siloed programs and not concept. analysis of clinical, demographic, systematically triggered by and socioeconomic indicators and agency-wide processes. shared among Medicaids and other public programs Outreach is primarily manual States use Websites, Agencies use Outreach triggers are event and conducted by paper or TV, radio and advertisements to driven. phone. distribute outreach information to targeted members Outreach materials are Agencies support deployment of Peer2peer business process manually prepared and internet access points. collaboration between the Agency updated. and EHRs or other program applications. Identification of targeted The business process is primarily Access to standardized electronic members is based primarily on electronic, with paper used only clinical data facilitates member records and limited to secondarily. identification of and may trigger current program information. electronic messages to members in need of outreach and/or education. Outreach to prospective Use of electronic communications Coordinated outreach and members is sporadic and lacks makes production of appropriate education can be regional and analysis needed for targeting outreach material more feasible Pan-Medicaid in scope. specific populations. and cost-effective. Current and prospective Access to standardized electronic Outreach material are members have difficulty clinical data as well as use of GIS automatically generated and sent locating needed information and socio-economic indicators to members in response to because of siloed programs. support targeting populations for requests made via email or PHRs, outreach. or by scheduled release. Education materials are lacking Shortened time for materials to Staff focuses on maintaining a because difficult and costly to reach the members. data base of functionally, produce. linguistically, culturally, and competency appropriate outreach and education materials. Quality and consistency of Member registries use Triggers create messages from outreach and education efforts standardized contact data members' EHRs/PHRs that map are difficult to maintain. to automated response messages. Primarily an all manual Members are able to access Turnaround time for sending process. information regardless of their appropriate information is channel of inquiry. immediate on a national or regional scale. Members must wait in phone Outreach materials are developed Turnaround time to identify target queue to make inquiries and and stored in electronic format member and transmit information may have to contact multiple and made available to members is immediate. programs to access the needed via a Web portal, public media, or information. kiosks. Mailings take a number of days Outreach and education materials Nearly eliminates time current to produce and send. are available via state Medicaid and prospective members must portal and are shared with other spend discovering and submitting collaborating agencies. needed information to all social services. Due to lack of electronic Access to electronic sources or Access to standardized clinical sources or outreach and outreach and education materials data facilitates identification of education materials, current greatly reduces time that current targeted current and prospective and prospective members must and prospective members must members. spend a great deal of time spend discovering needed discovering needed information. information. Preparation of materials is Automation improves access and Standardized services support clunky. Information is subject accuracy. application interfaces for to inaccuracies and electronic interchange of outreach inconsistencies. and education material to targeted . . . Lack of functionally, Current and prospective members Outreach and education materials linguistically, culturally, and can access needed information via can be effectively pushed on an as competency appropriate Web portal. needed basis because of outreach and education standardized data used by materials likely limit members' Member Registries nationally. access to information Mailings are not delivered Increased standardization of Standardized business process because contract data in administrative data, and improved collaboration protocols support members' records do not meet data manipulation for decision application interfaces for NPS standards. support improves accuracy of peer2peer outreach and education populating targeting processes. Staff develops and maintains Increasing use of functionally, Access to clinical information materials manually linguistically, culturally, and improves efficiency by competency appropriate outreach automatically mapping member and education materials improve who needs assistance with members' access to information generation of appropriate materials. Developing functionally, Member information is accessed Automated business rules that linguistically, culturally, and via federated Member Registries include clinical data lead to faster competency appropriate that can be accessed by all identification of target outreach and education authorized entities within the populations. materials is difficult. state. Effort is required to research Algorithmic identification of and Outreach and education materials target current and prospective analysis based on standardized can be effectively pushed on an as target populations and track data to targeted members improve needed basis regionally or mailings. in accuracy. nationally via federated Member Registries. Mailings are not delivered Use of NPS standards for member The target population analysis is because of inaccurate, data improves accuracy for based on real time access to nonstandard contact mailing purposes. health and socioeconomic information, resulting in need indicators drawn from to follow up with members by standardized person/patient data other means or missing outreach and education opportunities. Process is labor-intensive. Populations are targeted more Full automation of the process of effectively because programs are identification of need, mapping to able to share member analysis. the right message, plus access to clinical data reduces staff requirements to a core team of professionals who monitor the education and outreach process. Paper materials are expensive Materials can be posted on a Web Outreach and education can be to produce. site for downloading by members. interoperable among states sharing business services, reducing redundant effort and optimizing delivery of appropriate needed material real time to the point of care. Incurs postal expenses and cost Fewer staff required to support. Incorporation of clinical data of undelivered mail. improves accuracy of identification of targeted members and dissemination of appropriate messages. Staff still needed where the Delivery of appropriate outreach Member registries improve materials are not appropriate and education materials is eased accuracy of contact information. for member. with electronic and public media channels. Difficult to determine impact National standards are developed Access to member information on of outreach and education. for creation education and a regional or national basis. outreach materials. Current and prospective Business services are developed Outreach and education members continue to need and shared nationally to support communications can be triggered assistance by phone. target population identification. by automated messaging. Business process complies Mailings are more successful Use of clinical evidence creates with agency and state because member records have better target groups and improves requirements for educating the NPS standard data and member consistencv of results members regarding rules and registries1 use algorithmic regulations and how to identification to improve data communicate with the Agency. accuracy. Automation reduces level of Access to member information on staffing required to target a regional or national basis. populations needing outreach and education. Availability of online materials reduces paper and mailing costs. Collaboration, data sharing, and shared services increase cost- effectiveness. NPS standard member contact information decreases undelivered mailings. Use of portal by members is monitored to ensure that a sufficient number of the targeted populations are actively engaged in downloading information. Agency can target members who are not accessing informatioa Business services standardize messages sent to members. The members and the agency benefit from introduction of automation to speed up the outreach and education process. Agencies benefit from sharing of the business service and information with other agencies. Members benefit from consistency and timeliness of the information transmitted

TABLE 64 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Service Authorization Capability: Authorize Referral Basic Competitive Market Leading At this level, the Authorize At this level, the Authorize The process queries national and Referral Request process is Referral process transaction, regional registries for pointers to performed primarily using a receives only EDI transactions repositories of member's clinical paper/phone/fax process. via electronic means that support data and provider credentialing even small, rural, and waiver and sanction data for prospective providers. program integrity audits. Review of authorization Web portal support error free Meta-data is used to locate the requests are performed submissions with data field records and to ensure semantic manually which is resource masks, client-side edits, and inoperability of the data even intensive, untimely and may pre-populated fields. where the data mav be based on result in inconsistent: different coding schemes or data Application of business rules models. Review of authorization The service requests may be Inter-enterprise business process requests are performed accepted by internet Web portals, management between Medicaid manually which is resource email, dial-up, and via systems and Clinical data during intensive, untimely and may transferable electronic media such an episode of care eliminates the result in inconsistent: as disks and tape. need for providers to submit Communication of errors to referral data providers Review of authorization If a referral data set fails review, Real-time access to source data requests are performed rather than the reviewer having to ensures accuracy and improved manually which is resource manually contact the submitter, process performance. intensive, untimely and may the process can now generate an result in inconsistent: electronic request for additional Decisions on the need for or information via an XI2 277. sufficiency of additional information If the referral request requires Standardized data enable tracking Member and provider data additional information, the overutilization of similar services accessible in regional registries reviewer must manually contact that are coded differently for are recognized by all participating the submitter/provider, which prospective program integrity and applications as the “source of delays processing and is tracking contraindication of truth”. resource intensive. services provided for medical appropriateness. Format and content is not Service referrals no longer need HIPAA compliant, and is likely to be checked because business state-specific. rules alert the provider about clinical prerequisites for service coverage. MCO use of service authorization can be monitored for underutilizations by review of the encounter data. The service requests are There are established RHIOs and primarily manually validated semantic interoperability. against state-specific business rules. However, when there is automated validation, rules lack flexibility.

TABLE 65 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Service Authorization Capability: Authorize Service Basic Competitive Market Leading Authorize Service request is The Agency receives EDI Service authorization is embedded primarily paper, phone or transactions via electronic means in the provider to payer system faxbased. Format and content that support even small, rural, and communication. As the provider are not H1PAA compliant. waiver providers enters service data into the CLINICAL DATA, authorization is immediately established by the payer application. Each state has developed many Web portals support error free Capabilities are expanded to a paper forms to support this submissions with data field national base of data via NHIN. process. Information is masks, client-side edits, and pre- manually validated and populated fields. manually transferred from submitted paper to the MM IS. If a Authorize Service request Processes generate an electronic The Medicaid agency and requires additional information, request for additional information providers establish pointers to the reviewer must manually via an X12277 if additional national repositories of member's contact the submitter/provider, information is required. clinical data Direct access to which delays processing and is Clinical data eliminates the need resource intensive. for additional information within the Authorize Service process. Authorize Service requests are The process is completely Meta-data is used to locate the primarily manually validated automated and only rare records and to ensure semantic against statespecific business exceptions must be manually interoperability of the data even rules. reviewed. where the data may be based on different coding schemes or data models. Inflexibility in Authorize Processing is highly flexible so This data takes the form of virtual Service processing is a key that rule changes can be made records used to inform the factor in the proliferation or quickly and inexpensively in Authorize Service process. siloed systems outside of the response to need for new or MMIS. different rules Especially for waiver programs The process uses complex The process is an inter-enterprise that determine medical algorithms and the application of business process between appropriateness and service structured clinical data allowing Medicaid systems and Clinical authorization differently than for high automation. data during an episode of care. traditional Medicaid programs All programs use semantically Through peer-lo-peer interoperable data in the process. collaboration, the CLINICAL DATA assists the provider with Medicaid clinical protocols required for coverage. Standardized data and Authorize There are established RHIOs and Service rules enable tracking of semantic interoperability overutilization of similar services that are coded differently Related processes are decoupled, allowing changes to be made in the Authorize Service process with reduced potential for unintended downstream processing consequences.

TABLE 66 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Service Authorization Capability: Authorize Treatment Plan Basic Competitive Market Leading The Authorize Treatment Plan The process is a mix of paper/ The process is simplified querying process is performed primarily phone/fax and EDI. The national and regional registries for using a paper/phone/fax process. authorize treatment plan requests pointer to repositories of may be accepted by internet Web member's EHRs for clinical data portals, email, dial-up, and via and provider credentialing and transferable electronic media such sanction data for prospective as disks and tape. program integrity audits. Review of authorization of The Web portals support error free Meta-data is used to locate the treatment plan requests are submission with data field masks, records and to ensure semantic performed manually. client-side edits, and interoperability of the data even pre-populated fields. where the data may be based on different coding schemes or data models. If the treatment plan request If a treatment plan data set fails Interenterprise business process requires additional information, review, rather than the reviewer management between Medicaid the reviewer must manually having to manually contact the systems and Clinical data during contact the submitter/provider. submitter, the process can now an episode of care eliminates the generate an electronic request for need for providers to submit additional information via an treatment plan data X12 277. Format and content is not Standardized data enable tracking Real-time access to source data standardized and is likely state- of over-utilization of similar ensures accuracy and improves specific. services that are coded differently process performance. for prospective program integrity and tracking contraindication of services provided for medical appropriateness. The requests are primarily Member and provider data manually validated against state- accessible in regional registries specific business rules. are recognized by all participating applications as the “source of truth”. When there is automated Treatment plans for claims no validation, rules lack flexibility longer needs to be checked and are costly to change. because Medicaid business rules alert the provider about clinical prerequisites for service coverage Related processes are tightly There are established RHIOs and integrated, making it difficult to semantic interoperability. ensure that changes to service authorization process do not result in unintended crossprocess consequences. Maintenance is expensive and time-consuming.

TABLE 67 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Member Payment Information Capability: Calculate Spend-Down Amount Basic Competitive Market Leading The Calculate Spend-Down The business process is conducted Providers enter new service Amount business process is electronically and does not require information into clinical records primarily paper based. An that members report their costs. at various locations if a client is applicant's costs for health flagged as a candidate. services are tracked by adding paper bills and receipts until the spend-down amount for each period is met Applicants may be required to Members are made eligible for submit a paper spend-down Medicaid coverage with a report deductible amount equal to their spenddown requirements for the specified period. Stall applies spend down rules Applicants submit electronic to decide whether the submitted spend-down reports, and either costs are allowable and in which scan, fax, or mail health care bills period to apply the costs, and receipts. sometimes resulting in inconsistent determinations or controversy with the applicant. If spend-down is met, staff keys Agencies support transmission of change in eligibility status into spend down information on the the applicant's record so that X12 270-271. subsequent claims will pay for a specified period. Providers are able to determine the spend-down amount when they verify eligibility. The member's account accumulator automatically accounts for excess resources during claims processing by debiting the amount paid by the member Once spend-down has been met. Medicaid payments to begin and/or resume.

TABLE 68 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Member Payment Information Prepare Member Premium Invoice Basic Competitive Market Leading The agency uses manual Information from all program procedures to maintain member eligibility systems is used to accounting for premium establish the amount of the invoicing and payment. member liability in a centralized member accounting system associated with the Member Registry. The agency uses manual Member liability amounts are procedures to maintain updated by MMIS with online transaction history of all monies adjustment capability. received or paid out of the member account The agency uses manual The process creates a debit when procedures to reimburse payments are made, members for HIP payments; and overpayments are credited to the support member contribution account and refunds made to the accumulators to determine out member by check, EBT. of pocket maximums or spend down requirements. Member liability records are Notices automatically are sent to siloed by program and based on the member from a central program specific eligibility enterprise-wide member records. communications management business area. Invoicing and payment receipt Member cost sharing accounts are are manual processes requiring maintained and updated by claims data entry for payment or member direct premium or pay processing and for the changes in payments activity. in member liability due to eligibility status. Member accounting may be Total payments are automatically program specific, resulting in compared to the member's benefit members receiving invoices and package requirement for out of reimbursement from, and pocket expenses. making premium payments to different parts of the Agency. Total payments are manually Payments can be accepted at all compared to the member's Agency sites. Payment can be in benefit package requirement for the form of cash, check, or credit out of pocket expenses. or debt card. Notices are manually generated Details of the transaction are and sent on paper to members posted to the member accounting advising them of their hearing modules on the MMIS and then rights and the amount of their sent to the Agency financial contribution. systems.

TABLE 69 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Claims/Encounters Adjudications Capability: Apply Claim Attachment Basic Competitive Market Leading Paper claims attachments are The agency receives a mix of Attachments are no longer sent separately from the claim; paper and electronic attachments. required because the payer has the two documents are matched Electronic attachments are direct access to the clinical data up, requiring some manual automatically matched to stored in the clinical data record. intervention corresponding claim. There are limited, Electronic attachments meet Through the NHIN, the Medicaid agencyspecific requirements for HIPAA standards and MITA agency can view clinical data the attachments. Medical standard interface requirements stored in Clinical data in any records are delivered in paper with agency-specific location in the country. format with no standards. Implementation Guide instructions. Some manual processing is still required. Claims requiring attachments Electronic attachments are Clinical information needed for are subject to delays. required for electronically adjudicating payment for a submitted claims. service is instantly accessed (including nationally). Manual matches and reviews Agency continues to accept paper Access is immediate, with data result in inconsistency and attachments from a small number available nationally. errors. of disadvantaged providers who still submit paper claims Labor-intensive, requires Electronic attachments shorten Accuracy increases based on professional review staff. time required to match with claim direct access to source clinical and edit. data, no translation. Costly, but meets agency goals Use of MITA national standards No human intervention is for ensuring appropriateness of for claims attachments increases required on a national scale, payment. speed of processing. therefore, maximum efficiency. There are inconsistencies in Electronic attachments increase Maximum accuracy results in the manual matching accuracy State complies with and processing of attachments. HIPAA standards but also has its own IG requirements. Electronic attachments are required for electronic claims and a MITA national standard is used. This increases access and accuracy of data Electronic attachments reduce staff requirements. More managed care enrollment means fewer claims/attachments. Use of MITA national standards for the Claim Attachment facilitates performance. Accuracy is improved

TABLE 70 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Claims/Encounters Adjudications Apply Mass Adjustment Basic Competitive Market Leading The agency identifies the claims Improvements throughout the to be adjusted, sets Medicaid program operations the parameters, and applies the reduce the number of mass retroactive rates through adjustments required. primarily manual processes. Identification of claims to be adjusted and application of the adjustment are automated with audit trail. Adjustment data is specific to the agency. MITA standard interfaces for mass adjustments are used by the state Medicaid agency.

TABLE 71 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Claims/Encounters Adjudications Audit Claim-Encounter Basic Competitive Market Leading The agency recieves paper The agency continues to accept Direct connection between claims, EDI transactions, and paper claims from a small number Medicaid systems and providers' POS conforming to state of disadvantaged providers, but Clinical data during an episode of standards. the majority of transactions are care eliminates the need for submitted electronically. providers to submit claim data or attachments requiring editing. Paper transactions are batched Electronic transactions meet Through peer-to-peer and scanned (or data entered). HIPAA data standards. collaboration, member and provider data accessible in regional registries are recognized by all participating applications as the “source of truth”. State-specified data elements Electronic transactions meet The process queries national and trigger the Edit and Audit MITA data standards. regional registries for member Claim/Encounter business and provider information. process. Encounter data is recieved via Payer-specific implementation The process is able to locate and tape in state-specified format Guides are replaced by MITA query the members' Clinical data and data content. standards. to validate health status data. Sister agencies and waiver Translators convert national data The Edit process can rely on the programs manage their own Edit standards to statespecific data to real-time updates to the Reference and Audit Claim process. support business processes. Repository from authoritative sources for definitive coding schemes. Payer implementation Guides The business process uses MITA The process can locate members' impose additional payer-specific standard data and therefore no primary payers' benefit repository rules. translation is required. to access services covered under each third-party resource. Suspend claims require Encounters are submitted as There are established RHIOs and lengthy manual resolution. HIPAA compliant COB claims semantic interoperability. from managed care organizations and any other external processor. Data are not comparable across Encounter data meets MITA Real-time access to source data silos. standard interface requirements. ensures accuracy and improves process performance. For EDI claims/encounters Medicaid agency coordinates with Real-time access to source data edits are automated for many other sister agencies and waivers enables enhanced business steps, but are manual for programs to accept, process, and activity monitoring is baesd on attachments and suspended access MITA standard data optimal data streams to fine-tune claims/encounters: elements. business process rules to meet Claims/encounters EDI format operational parameters, thereby and content is not HIPAA ensuring that Agency objectives compliant. are met. Attachment data is unstructured Electronic claim processing and Access to additional data form It is difficult for reviewers to POS adjudication greatly increase national sources adds to accuracy consistently interpret and apply timeliness. of editing. adjudication rules. For EDI claims/encounters, Waiver claims continue to be Claim processing is replaced by edits are automated for many steps, submitted to siloed payment direct communication between but are manual for systems using state specific provider system and payer attachments and suspended format and data, such as provider system. claims/encounters. type and service codes. COB is conducted by denying All programs, even those not All claims for members with claims using the resource covered under HIPAA, use known third-party's resources are intensive payer-toprovider semantically interoperable data in flagged for payer-to-payer COB, model. the edit prcess. reducing provider burden and improving thre timelines of reimbursement. Edited fields are validated If a claim/encounter data set fails Related processes are decoupled, against standard and edit validation, the process can allowing changes to be made in state specific code sets. now generate an electronic the Edit/Encounter process request for corrections via an X12 with reduced potential for 276. If additional information unintended downstream is required, an electronic request is processing consequences. made, e.g., via an X12 277. Maintenance is expensive and Standardized data and edit rules The process is completely time-consuming. enable tracking of overutilization automated and only rare edit of similar services that are coded exceptions must be manually differently for disallowance. reviewed. Optimizing automation improves error rates and timeliness, thereby enabling support of real-time claims/encounter processing. Rules lack flexibility and are All siloed payment systems are costly to change. Therefore, integrated or retired, saving when new programs, code sets, resources and optimizing FFP, and or edits are added, claims/ data quality is improved. encounters with these changes may need to be edited manually, which may not be cost effective in the long term. Results meet agency Edit processing is highly flexible requirements for timeliness and so that edit rules and code set of accuracy. changes can be made quickly and inexpensively. Edit rules engines support complex algorithems so that benefit packages can be customized for members eligible for multiple programs Edits can be structured for both traditional and waiver programs Maintenance continues to be expensive and timeconsuming Despite progress, related processing continue to be tightly integrated, so that changes to edit can result in unintended downstream processing

TABLE 72 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Claims/Encounters Adjudications Price Claim-Value Encounter Basic Competitive Market Leading Standard Medicaid services are More services are automatically Pricing is embedded in the automatically priced using rate priced and there are fewer “by- provider to payer system and fee reference data. Values report” manual pricing communication. As the provider are assigned to services reported exceptions. enters service data into the on encounters, using the same clinical record, authorization and reference data. pricing are immediately established by the payer application. “By-report” pricing is Medicaid agency coordinates with The agency uses the NHIN to performed manually. sister agencies and waiver compare and select prices based programs to present a one-stop on regional averages or other new shop claim adjudication and pricing methodologies (TBD). pricing process. Staff manually prepare Most single claim adjustments are Supports regional pricing profiles adjustment transactions automated. that can be factored into the including application of member pricing methodology. contributions, provider advances, deduction of liens and recoupments. Waiver program and a-typical State Medicaid agency can For example, a new pricing rule: provider services are manually support payment of waiver “Pay the amount billed or the priced. program and a-typical providers. regional average (Region = ME, NY, VT), whichever is lower” . . . or, “Pay the regional per diem no matter what is billed”. The agency uses MITA standard interfaces to price claims and value encounters. Flexible business rules allow maximum flexibility in changing pricing algorithms. Pricing formulas are agency specific.

TABLE 73 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Cost Avoidance Perform Cost Avoidance Functions Basic Competitive Market Leading 10.8.1.1 Identify and verify other insurance/third party resource information according to clams received 10.8.1.2 Send collection letters to other responsible parties for payment due to Medicaid 10.8.1.3 Provide and process reports to monitor cost avoidance effort

TABLE 74 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Cost Recoveries Manage Drug Rebate Basic Competitive Market Leading At this level, the business The business process uses Drug rebate is replaced by a new process is primarily paper electronic interchange and strategy where care management invoice processing. automated processes to support and disease management interact state generation of rebate with provider EHRs. information. Rebate information is manually The business process uses Data exchange is on a national validated. MITA standard interfaces. scale. Programs are siloed so rebate Agencies centralize drug Through peer-to-peer process may be uncoordinated utilization data from siloed collaboration, real-time access to and shared programs with health programs as inputs to the drug source data ensures accuracy, departments pay for drugs but rebate process. eliminates redundant collection may not participate in the state and interchange of data, and drug rebate program. improves process performance. Non-standardized data and Data is standardized for format makes any type of cross automated electronic interchanges program management reporting (interfaces) between agencies and and analysis for drug rebate drug manufacturers. purposes is difficult and costly. Access to data is limited by Communications are more legacy systems and CMS consistent, timely and appropriate. reporting cycles Reporting, analysis, and responses to inquiries are not timely and data may not be accurate. Cost-effectiveness is impacted by lack of data accuracy and completeness, manual processing, and need for CMS quarterly reporting of rebate information.

TABLE 75 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Cost Recoveries Manage Estate Recovery Basic Competitive Market Leading At this level, the business The business process has almost The data exchange necessary for process is primarily a mix of eliminated its use of nonelectronic estate recovery is accessed for paper, phone, fax and interchange and has automated member and third party resources proprietary EDI. most processes to the extent on a national scale. feasible. Nonstandardized data and Agencies are standardizing data to Through peer-to-peer format from multiple sources increase coordination and collaboration between the agency requires manual compilation of consistency. and provider EHRs or other data. program applications. Access to data is limited by the MITA standard interfaces are used e.g.. For example, health sporadic, inconsistent, and for electronic interchanges departments for date of death untimely receipt of data and (interfaces) between agencies. matches, realtime access to source updates to member eligibility. data ensures accuracy, eliminates redundant collection and interchange of data and improves performance. Generating correspondence is Communications to stakeholders not timely. and member's personal representatives are consistent, timely and appropriate. Cost effectiveness is impacted by lack of data accuracy and completeness, and manual processing.

TABLE 76 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Cost Recoveries Manage Recoupment Basic Competitive Market Leading At this level, the process is The process has almost eliminated The process interfaces with other likely primarily a manual its use of nonelectronic processes via federated process. interchange and has automated architectures and collaborates most processes to the extent feasible. with other processes in a peer2peer environment, eliminating redundant collection and interchange of data, and improving realtime, multi-axial processing. Communications to providers More of the formatting is HIPAA and other payers are compliant resulting in accomplished via phone and standardizing data to increase its mail. usefulness for performance monitoring, management reporting, fraud detection, and reporting and analysis. Format is not HIPAA complaint, There is more application-to- recouping of monies in third application communications party liability situations is which results in less manual accomplished from payer to intervention resulting in less provider rather than payer to maintenance and time savings. payer. Non-standardized data makes Data is standardized for any type of cross program automated electronic interchanges performance monitoring, and interoperability. management reporting, fraud detection, or reporting and analysis difficult and costly. Communications to providers are consistent, timely and appropriate.

TABLE 77 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Cost Recoveries Manage Settlement Basic Competitive Market Leading At this level, the business The business process has almost The business process interfaces process is likely primarily paper eliminated its use of nonelectronic with other processes via federated based processing and some interchange and has automated architectures and collaborates proprietary EDI. most processes to the extent with other processes in a feasible. peer2peer environment, eliminating redundant collection and interchange of data. Nonstandardized data makes Data is standardized for The business process interfaces any type of reporting and automated electronic interchanges with other processes via federated analysis difficult and costly. (interfaces). architectures and collaborates with other processes in a peer-to- peer environment, improving realtime, multi-axial processing. Programs create inconsistent Agencies centralize common rules across the Agency and processes to achieve economies Agencies apply their own rules of scale, increase coordination, inconsistently. improve rule application consistency, and standardizing data to increase its usefulness for performance monitoring, management reporting and analysis.

TABLE 78 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Cost Recoveries Manage TPL Recovery Basic Competitive Market Leading The process is primarily a mix The process uses agency specified COB is automatically coordinated of paper, phone, fax and electronic interchange and through the RHIO registry. proprietary EDI. automated processes. Information regarding third- The business process uses MITA Data exchange for COB occurs on party resources is manually standard interfaces for payer-to- a national scale. validated. payer COB process. TPL recovery is accomplished Electronic or magnetic tape Response and payment outcomes primarily via paver-to-provider downloads from other agencies are immediate. COB. are used for data matches support access to member eligibility data. Inconsistency in the rules Data is standardized for Regional stakeholders are applied to TPL recoveries vary automated electronic interchanges interoperable and payment from agency to agency. (interfaces) between agencies and determinations or denials are other payers. entirely a payer-to-payer process making the data immediate, accurate and consistent. Programs are siloed so the Communications are consistent, Through peer-to-peer recovery process may be timely, and appropriate. collaboration, member and uncoordinated. provider data is accessible through RHIO relays across the country. Non-standardized data and format makes any type of cross program management reporting, and analysis difficult and costly. Access to data is limited by inter-agency and other payer legacy systems. Cost-effectiveness is impacted by lack of data accuracy and completeness, as well as inconsistency in how the rules and/or policies are applied to TPL recoveries, manual processing and timeliness.

TABLE 79 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment and Capability: Reporting Management Prepare COB Basic Competitive Market Leading Medicaid agency identifies The agency uses MITA standard The previous COB process claims subject to COB prior to interfaces for claim adjudication is replaced by payer to payer payment (Cost Avoidance) and COB. The prepare COB communications. based on defined criteria. process is completely automated and only in rare exceptions requires manual intervention. The claim subject to COB is Cost avoided claims are The agency can query registries denied and returned to the immediately forwarded to primary across the country for pointers to provider indicating requirement payers. Some claims are flagged repositories of member's third to bill the primary payer first. manually for forwarding to a third party resources. party on an exception basis. Post payment recovery (Pay and Post payment recovery (Pay and Meta-data is used to locate the Chase) claims are sent to third Chase) claims are submitted to records and to ensure data party payers using a mix of third party payers using MITA interoperability. paper and EDI claims with non- national standards. standard data resulting in inconsistent application of rules, delays, and labor intensive efforts. It is difficult to adapt to new Flagging of post payment Real-time access to source data policies for COB. COB recovery claims is completely ensures accuracy and improves processes are closely integrated automated and only requires process performance. with claims adjudication, manual identification of recovery pricing, and remittance advice, claims under limited so changes affect all the circumstances. Optimizing interrelated processes. automation improves error rates and timeliness of this process. Maintenance is expensive Post payment recovery processing and time-consuming. is highly flexible and supports complex algorithms. Related processes are decoupled, allowing changes to be made in the Prepare COB process with reduced impact on related business processes. All COB is coordinated among data sharing partner agencies in the state.

TABLE 80 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capability: Payment and Reporting Management Prepare EOP Basic Competitive Market Leading Medicaid agency complies with Medicaid agency enhances the EOMB is replaced by a Personal federal regulations to produce sampling process to target Health Record. random samples of EOMBs selected populations. quarterly and mail to members. Members are asked to read the EOMB and report on any discrepancies. Sensitive services are Member responses are Personal Health Records are suppressed. automatically tabulated. accessible anywhere in the U.S. via the NHIN. Cultural and linguistic The agency has access to clinical adaptations are introduced. data and can directly analyze services recorded and reported. The agency uses MITA standard The agency can communicate interfaces for the EOMB. with individuals who appear to need special attention. Other agencies collaborate with Medicaid in the EOMB process.

TABLE 81 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment Capability: Prepare Home and Reporting Management and Community-Based Services Payment Basic Competitive Market Leading The Prepare Home & The Medicaid agency works with HCBS programs benefit from Community-Based Services HCBS programs to share payer system to provider system Payment business process is Medicaid processes. communications for immediate primarily paper/phone/fax based approval of payment. processing with limited EDI. HCBS programs are separated Medicaid agencies and sister Payments can be made anywhere and uncoordinated. There is no agencies agree to use MITA in the U.S. standardized data. standard interfaces for payment transactions. Payments are non-standard and Some HCBS programs use cover a variety of atypical Medicaid business processes for Payment authorization is providers. Some payments are service authorization and service embedded in the provider to payer salary-based. payment. system communication. As the provider enters service data into the clinical data record, authorization is immediately established by the payer application. HCBS providers agree to use Medicaid standards for price authorization and claims adjudication and payment.

TABLE 82 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment Capability: Prepare and Reporting Management Premium EFT-Check Basic Competitive Market Leading Medicaid agency or Department Medicaid agency complies with Payments are made directly to of Finance produces the EFT state or industry standards for provider bank accounts triggered transaction or a paper check EFT transactions and conforms by entries into clinical records using Medicaid agency or state with HIPAA where appropriate. maintained by the provider and DOF standards for format and accessed by the payer. data content. Agency encourages electronic EFT payments are distributed to billers to adopt EFT payment. any location in the country via the NHIN. The agency uses MITA standard Premium payments are made interfaces for EFT transactions directly to MCO, insurance Paper checks are produced where company. Medicare buy-in, et al required for exceptional bank accounts based on circumstances. enrollment information. All electronic billers receive EFT payment. Through inter-agency coordination, multiple agencies share the same EFT process.

TABLE 83 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment Capability: Prepare and Reporting Management Provider EFT-Check Basic Competitive Market Leading Medicaid agency or Department Medicaid agency complies with Payments are made directly to of Finance produces the EFT state or industry standards for provider bank accounts triggered transaction or a paper check EFT transactions and conforms by entries into clinical records using Medicaid agency or state with HIPAA where appropriate. maintained by the provider and DOF standards for format and accessed by the payer. data content. Agency encourages electronic EFT payments are distributed to billers to adopt EFT payment. any location in the country via the NHIN. The agency uses MITA standard Premium payments are made interfaces for EFT transactions directly to MCO, insurance Paper checks are produced where company, Medicare buy-in, et al required for exceptional bank accounts based on circumstances. enrollment information. All electronic billers receive EFT payment. Through inter-agency coordination, multiple agencies share the same EFT process.

TABLE 84 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment Capability: Prepare and Reporting Management Remittance Advice-Encounter Report Basic Competitive Market Leading Medicaid agency produces the The Medicaid agency complies With provider clinical system to paper Remittance Advice using with HIPAA to supply an payer system communication, the state Medicaid agency specific electronic RA that meets state RA is replaced by a new format and data content. agency Implementation Guide accounting mechanism, (TBD). requirements. Explanations of codes are The agency uses MITA Payment information can be sent comprehensive and agency standard interfaces for the RA. to any location in the country via specific. Paper RAs are still supported the NHIN. on an exception basis. All electronic billers receive ERAs. Through inter-agency coordination, multipleagencies can use the same ERA data standard.

TABLE 85 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment Information Management Capability: Inquire Payment Status Basic Competitive Market Leading The claim status inquiry process Programs employ AVR, legacy Claims processing is replaced by is primarily a manual process direct data entry, and point of direct communication between the and is associated with a specific service devices for electronic provider's CLINICAL DATA service. claim status responses. Staff may system and the payer system. still manually handle inquires that Adjudication results are known are not resolved with automated immediately, eliminating the need response. for claim status inquires. Providers inquire about the The data uses agency standards Inquiries can be launched and current adjudication status of a and access is less timeconsuming, responded to nationally through claim by phone, fax, or paper. less burdensome, and requires the NHIN. Staff performs search on the fewer agency resources. claims history data store (for claims in process) or the claims history repository for claims that have been adjudicated. Search may be based on the All programs use a centralized Provider system collaborate with claim ICN, date of service, or automated electronic claim status the MMIS during an episode of patient name. Staff locates the process. Interfaces use MITA care. The providers' systems alert data and relay it to the provider standards. Providers send the provider to any clinical by phone, fax or paper. Process HIPAAX12 276 or use online protocols and to any business is timeconsuming for providers direct data entry and receive rules required by the agency in and resource intensive for HIPAAX12 277 response or find order for the service to be paid. agency. the claim status online. Data is standardized; access is When the episode of care has 24 × 7, and is completely concluded, the service is automated for the provider. reimbursed or not and the provider knows the payment status immediately, eliminating the need for payment status inquiry.

TABLE 86 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Payment Information Management Capability: Manage Payment Information Basic Competitive Market Leading At this level, the business The business process is now an The business process interfaces process is focused primarily on enterprise resource that provides with external business processes meeting traditional FFS program real time access to quality, via regional record locator needs as reflected in MMIS complete and semantically services. certification requirements. interoperable data via record locator services that federate all programs' payment history. Data is largely nonstandardized Data sources are primarily The business process collaborates and vary by siloed programs. electronic interchange. with other processes in a peer2peer environment, eliminating redundant collection and interchange of data, and improving realtime, multi-axial processing. Payment data is not timely. All programs use HIPAA 837 data Claims are no longer sent or for claims history records. compiled by the Agency, and instead, users of claims history data locate and compile clinical episode of care data within EHRs via record locator services or search engines on a real time, as need basis. Data availability is limited by Claims attachments are compliant Profiles of Medicaid enterprise siloed systems' reporting with the X12 275. payment history by member, capabilities. provider, service or condition are accessible to authorized external users. Using payment data for Premium payment data is Record locator services may be profiling members, providers, compliant with the HIPAA 834. provided by semantic Web search program analysis, or outcome engines. measures requires costly and untimely statistical manipulation. All payment history data is stored Emerging use of online publish internally in accordance with a and subscribe capabilities or other standards-based UML data model. information content management capabilities enable push and pull of data to EHRs, PHRs and public health. Claims may be processed in real Applications pull and consume time, and automation of most data available via URIs provided adjudication and processes by semantic Web search engines. markedly improves the availability, quality, completeness and timeliness of payment data. Decision support and sophisticated analytic tools enable users to compile member, provider, service or condition specific profiles and perform complex ad hoc analysis and reporting in real time.

TABLE 87 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capitation and Premium Payment Capability: Prepare Capitation Premium Payment Basic Competitive Market Leading The agency identifies members The agency implements HIPAA- Payments are made directly to who have elected or have been compliant standards for electronic managed care bank account via auto-assigned to a managed care premium payments, however, the RHIO registries. organization, a benefit manager, other insurance companies impose or a primary care physician, and their specific Implementation matches them to appropriate rate Guide requirements. cells, to calculate monthly payments. Agency may use a modified The agency uses MITA standard Agency can make premium claims adjudication process to interfaces which incorporate payments to any managed care support capitation payment HIPAA premium payment schema organization or insuring preparation. for identification of managed care organization at any location in the program enrollees, and country via the NHIN. preparation of the capitation premium payments. Adjustments are manually Business rules used to identify Clinical information is accessed applied. candidates are automated on a directly from the MCO/PCP if the state-specific basis. capitation payment is supplemented for special circumstances, e.g., high risk pregnancy. These steps are mostly manual. Some transactions continue to be manually processed at the request of the other insurer. Standards for the capitation The agency has the flexibility to payment transaction are agency- easily change the criteria for rate specific. cells.

TABLE 88 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capitation and Premium Payment Capability: Prepare Health Insurance Premium Basic Competitive Market Leading The agency identifies members The agency implements HIPAA- Payments are made directly to who meet criteria for buy-into compliant standards for electronic other insurer bank accounts via other insurance coverage premium payments, however, the RHIO registries. through primarily manual other insurance companies impose processes including a their specific implementation cost-benefit analysis of the Guide requirements. individual case. The agency enrolls the member The agency uses MITA standard Agency can make premium and receives premium payment interfaces for identification of payments to any insurer at any information. candidates for other payer buy-in, location in the country via the analysis of cost/effectiveness, and NHIN. health insurance premium payments. The agency pays the premium Business rules to identify Access to clinical information according to the insurance candidates and analyze helps to identify members eligible company requirements. cost/effectiveness are automated for other insurance programs. on a state-specific basis. These steps are mostly manual Some transactions continue to be manually processed at the request of the other insurer. If there are no standards for these The agency has the flexibility to transactions. easily change the criteria for identification of members eligible for other insurance buy-in. Medicaid collaborates with other payers to use the national standards.

TABLE 89 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Operations Management Sub-Platform: Capitation and Premium Payment Capability: Prepare Medicare Premium Payment Basic Competitive Market Leading The agency identifies members Medicaid agencies and CMS use a Agency can verify status of buy- who meet criteria for buy-in to standard interface for the in candidate in other states and Medicare Part B. premium payment. The agency jurisdictions via the NHIN before uses MITA standard interfaces for generating the premium payment. identification of candidates for Medicare Buyin. The agency exchanges Agencies use business rules to information with the SSA using improve identification of buy-in electronic communication candidates, prepare the premium standards specified by SSA. At payment calculation, and track the this level, tape exchange is the data exchange. primary medium. The agency prepares the The agency has the flexibility to Medicare Part B premium buy- easily change the criteria for in report. identification of buy-in candidates. The agency collaborates with other agencies to identify potential buy-ins.

TABLE 90 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Capability: Develop Sub-Platform: Health Informatics Strategy Basic Competitive Market Leading 4.1.2.1 Determine Key Business Objectives 4.1.2.2 Assess Current Business Environment against Market Evaluation 4.1.2.3 Assess Current Technical Environment 4.1.2.4 Define Organizational and Data Stewardship Needs 4.1.2.5 Create Informatics Vision in alignment with overall Business Strategy 4.1.2.6 Assess gaps between the current state environment and the Informatics Vision 4.1.2.7 Define Informatics Capabilities and Impact

TABLE 91 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Capability: Execution of Sub-Platform: Health Strategic Direction Informatics and Activities Basic Competitive Market Leading 4.1.4.1 Perform Data Mining/ Analysis 4.1.4.2 Conduct Statistical Evaluation/Estimation 4.1.4.3 Perform Predictive Modeling/Stratification 4.1.4.4 Conduct Reporting (Outcomes/Forecast/Risks)

TABLE 92 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Health Informatics Capability: Planning Basic Competitive Market Leading 4.1.1.1 Plan and Organize 4.1.1.2 Collect Industry Research and Best Practices 4.1.1.3 Gather Stakeholder Input

TABLE 93 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Enterprise Capability: Prioritize Sub-Platform: Health Informatics Activities Basic Competitive Market Leading 4.1.3.1 Perform Cost Benefit Analysis and Financial Impact Estimation 4.1.3.2 Determine Plan for Implementation of Capabilities

TABLE 94 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Procurement Capability: Internal Management Stakeholder Management Basic Competitive Market Leading 4.3.5.1 Performance Management 4.3.5.2 Process & Contract Compliance 4.3.5.3 Demand Management 4.3.5.4 Customer Service Oriented

TABLE 95 Global Health and Life Sciences High Performance Capability Assessment Model-Public Health Services-Medicaid Enterprise Sub-Platform: Procurement Capability: Requisition Management to Pay Operations Basic Competitive Market Leading 4.3.6.1 Transaction Processing 4.3.6.2 Master Data 4.3.6.3 Assisted Buying 4.3.6.4 MIS

TABLE 96 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Procurement Management Capability: Sourcing and Category Management Basic Competitive Market Leading Strategic Sourcing: “Three Strategic Sourcing Strategic Sourcing: Process rigor, quotes” approach solely done by Strategic Sourcing: Commodity/ dictated by common cross- procurement Cross team driven approach functional, analytical method Global Sourcing: deployed global sourcing strategy in place, penetrating new markets eSourcing: Simple reverse auction for all commodities Global Sourcing: Only done on Category Policy Setting Global Sourcing: Total landed an ad hoc basis Departmental policies, processes cost framework to fully leverage and procedures are in alignment LCC opportunities to reduce TCO with corporate policies eSourcing: Simple reverse Category Management eSourcing: Technology driving auctions for a few categories Framework Disparate category global collaboration, knowledge management structure that vary management and efficiency throughout the organization Procurement personnel dedicated to specific category management Departmental policies establish Compliance Monitoring Policies are established and standards of conduct and Compliance strategy in place, communicated to convey the promote compliance with reviewed periodically Corporation's position and applicable laws and regulations. philosophy; additionally, they provide governance over employees actions. No category management Centrally guided category framework established management structure that cut across organizational entities Groups of buyers Dedicated sourcing analyst pool that provides support during the sourcing and category management process Significant maverick spend Discipline, full control with non- compliance driving corrective actions

TABLE 97 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Procurement Management Capability: Supplier Relationship Management Basic Competitive Market Leading Reactive, only talking to Supplier Performance Targeted approach, differentiated suppliers when problems occur Management by supplier segment Supplier performance metrics established Procurement is involved and Supplier Integration Integrated product development urges groups to adopt industry Key suppliers are involved for involving customer focus groups or supplier standards input on alternate materials and suppliers and design teams, with design for manufacturability suppliers performing component issues development in line with overall Key suppliers are incorporated business and product strategy into planning process, forecast shared Limited to a few problem Contract Management Joint Process/Product solving meetings Some long term contracts in place Improvements, eSupply Chain on “big ticket” items or raw Integration materials Single contract management solution Horizon based on material Supplier Development Supplier pricing based on long requirements released to Vendor sharing of actual costs and term alliance agreements and procurement on requisition profit margins delivery is based on production Supplier development initiative schedule established Multiple contract databases and Centrally logged contracts, pro- ad hoc compliance management active mgmt of contract compliance Raw materials purchasing based Sharing of technical expertise to on competitive bids versus improve product performance and relationships reduce costs No systemic approach of Focus on repeatable LCC supplier supplier development development

TABLE 98 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Procurement Capability: Manage Human Management and Tangible Resources Basic Competitive Market Leading 4.3.1.1 Change Agency 4.3.1.2 Make vs. Buy 4.3.1.3 Competitive Awareness

TABLE 99 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Privacy and Capability: Manage Compliance Management Privacy Compliance Basic Competitive Market Leading 4.6.1.1 Maintain Training, Whistleblower Program, etc. 4.6.1.2 Manage Reporting Requirements 4.6.1.3 Manage HIPAA and State Privacy Compliance Maintain Privacy Office Maintain Authorizations Manage Disclosure 4.6.1.3 Manage HIPAA and State Privacy Compliance Maintain Protected Health Information (PHI) Manage Trading Partners Manage Security Manage Quality and Performance Privacy and Security 4.6.1.4 Manage Sarbanes-Oxley Compliance Manage Documentation and Data Retention Manage Attestation 4.6.1.5 Manage CMS Compliance

TABLE 100 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Legal Management Capability: Manage Legal Issues Basic Competitive Market Leading 4.2.1.1 Manage Legal Services 4.2.1.2 Ensure Regulatory Compliance 4.2.1.3 Provide Litigation Services 4.2.1.4 Provide Tax Advice 4.2.1.5 Advise Other Plan Departments 4.2.1.6 Manage Quality and Performance of the Legal Process

TABLE 101 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Capability: Manage Human Human Resources and Tangible Resources Basic Competitive Market Leading 4.5.1.1 Manage Workforce Capacity 4.5.1.2 Manage recruiting 4.5.1.3 Manage Compensation and Benefits 4.5.1.4 Manage Employee Services 4.5.1.5 Manage Training and Career Development 4.5.1.6 Manage Quality and Performance of Human and Tangible Resources

TABLE 102 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Capability: Architecture Information Technology Operations Management - Application Architecture Basic Competitive Market Leading Application suites documented Components are configurable and Related software and processes but without review and quality quality assurance practiced have been defined and actively control checkpoints monitored Application architecture Application suite architected Supporting software, development developed for pockets of considering planned service and maintenance processes projects only delivery commitments and improved to appropriate levels tracking (e.g. best in class) and focus on proactive fault prevention Some rationalization efforts, Application architecture defined Enterprise-wide application though fragmented and for functional groups architecture is actively managed inconsistent across groups for business value and regularly refreshed according to changing business and technical needs Integration layer is documented Application architecture is Application portfolio but without any review and consistently enforced rationalization opportunities quality control checkpoints integrated into new project objectives and planning Some standardized interfaces Application portfolio defined, Active process management for such as EDI or common tools rationalization process integration architecture in place documented and practiced consistently across all groups Integration architecture Integration/interface architecture considered across functional refreshed regularly units and quality assurance practiced in general Integration/interface architecture Interface re-use is actively is consistently enforced managed and enforced and considered in business cases Standards with supporting common integration tool sets (e.g., messaging, interface building, data transport) exist

TABLE 103 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Capability: Strategic IT Information Technology Operations Alignment - Business and IT Alignment Basic Competitive Market Leading Business and/or IT strategy is Business and IT strategy exist and IT strategy priorities are unclear and not fully there is some broad linkage continuously adjusted to match communicated between the two business needs IT and business work in their IT and business discuss alignment IT and business are jointly silos with mostly reactive and for critical projects responsible for defining IT one-way communications strategy and review the strategy on set schedule Where a strategy has been IT strategy is translated to The strategy is translated to clear articulated, it is often not operational levels at varying operational plans and for specific defined at an operational level levels of detail generally resulting audience, and tied to group and leaving it open to interpretation in consistent interpretation individual goals Strategy communication is Strategy communication Strategy communication ad hoc via varying channels to frequency, channels, audience are frequency, content and channels a fragmented set of audience defined, but still inconsistently are customized to audience and executed regularly managed IT has limited involvement in IT is typically involved in IT is involved in key Business Business Unit discussions, often Business Unit strategic strategic discussions to ensure the resulting in an incomplete discussions with the strategy strategy is comprehensive and strategic view and risk of generally inclusive of IT correctly executed deviation from the strategy implications and correctly executed IT initiative prioritization and IT initiative prioritization and IT initiative prioritization and approval process informally approval process defined with approved process proactively exists formal steps for business managed with business objective alignment, compliance involvement for all IT initiatives review and formal sign off by key decision makers, but not consistently followed It has limited influence on IT is involved in all strategic IT is a respected strategic partner strategic agenda initiatives consistently across to business enterprise Business IT Liaison plays a Business IT Liaison role is clearly Business IT Liaison plays a lead simple order taker role defined across business areas role in IT-enabled business transformation and acts as a change agent Business IT Liaison is equipped Business IT Liaison demonstrates Business IT Liaison maintains with limited “tools” knowledge of business processes deep knowledge of organization- and interactions across multiple wide IT roadmap, objectives, functional areas risks, interactions and issues Information feedback Feedback process on performance Proactive management of mechanism on performance or and customer satisfaction defined, performance feedback and customer satisfaction in place but not consistently enforced customer satisfaction results for continuous improvement

TABLE 104 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Capability: Information Technology Operations Solutions Delivery - Collaboration Basic Competitive Market Leading Informal and ad hoc sharing Sharing of key knowledge Proactive and ingrained sharing of between teams documentation exists throughout key knowledge documentation the life-cycle within IT and with throughout the life-cycle within the business customers IT and with the business customers No standards or guidelines as Knowledge sharing tools IT continuously looks for ways to how to store project deployed to facilitate capture and improve its knowledge sharing documentation distribution capabilities and regularly reviews its knowledge database Lack of adequate infrastructure Various repositories for project Knowledge is actively and tools to incite documentation, none used communicated and updated with communication completely or consistently feedback from all stakeholders Ad hoc and inconsistent Consistent processes across Proactive involvement of communication of knowledge groups/locations technology and business groups in optimizing knowledge communication Knowledge communication Communication ownership well ownership is loosely defined defined with leaders assigned by group, function or topic

TABLE 105 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: Strategic IT Alignment - Technology Operations Communicate IT Strategy Basic Competitive Market Leading Ad hoc communications of IT vision and strategy regularly IT vision and strategy regularly the IT vision and strategy communicated internally to communicated internally to various stakeholders and externally to various stakeholders Communications not aligned to the IT strategy refresh cycle

TABLE 106 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: IT Technology Operations Governance - Develop/Ad minister IT Budgets Basic Competitive Market Leading Informal IT funding model IT funding model allows for IT funding model designed to exists increases in IT spending to realize drive appropriate behaviors in defined benefits business and IT The allocation of IT budget is Allocation of IT budget is Allocation of IT budget is driven ad hoc and reactive partially influenced by business by business strategic priorities objectives Business managers participate in Business and IT managers work IT planning, and approve IT together throughout the year to priorities and allocations of funds allocate resources on the basis of on the basis of strategic priorities operational priorities

TABLE 107 Global Health and Life Sciences High Performance Capability Assessment Model Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: Architecture Technology Operations Management - End-User Computing Architecture Basic Competitive Market Leading End-user computing End-user computing architecture Active process management for requirements are documented considered across functional units end-user computing architecture but without any review and and quality assurance practiced in in place quality control checkpoints general Multiple end-user computing End-user computing architecture A small number of end-user devices, possibly including thin, is consistently enforced computing device configurations, 3270-like and thick clients with designed to deliver required multiple software configurations service at lower costs. Rudimentary business value End-user computing device set End-user computing architecture implications for end-user with planned set of hardware has been designed and computing architecture devices and managed software implemented with consideration configurations for overall application strategy, total cost of ownership and service targets, and is refreshed regularly Defined end-user computing configurations sets designed to deliver to clear service targets; supporting organizational structures and training

TABLE 108 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: IT Governance - Technology Operations Establish/Manage IT Standards Basic Competitive Market Leading IT standards are in its infancy Standards established by IT with Clear, consistent and Little enterprise-wide standards little or no input from business, comprehensive IT standards exist. with minimal accountability developed and maintained to guide decision making and action in accordance with established business and IT policies IT standards are after-thought Adherence to standards enforced Changes in business direction and and many business users periodically depending on budget strategy assessed to determine consider IT standards as pressures impact on relevancy of standards hindrance Unclear how IT standards would Standards changed often to allow Impact of business and be linked to external/regulatory for requested exceptions, or not technology trends on standards compliance examined for change at all assessed Internal and external audits are Changes to existing standards conducted to ensure standards clearly documented and compliance to external communicated to all affected regulations parties Dedicated compliance resources continuously monitors IT standards in lieu of changing external regulations

TABLE 109 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: Architecture Management - Technology Operations Infrastructure Architecture Basic Competitive Market Leading Infrastructure requirements are Infrastructure architecture Active process management documented but without any considered across functional units for infrastructure architecture in review and quality control and quality assurance practiced in place checkpoints general Infrastructure architecture Configuration management and Architectures designed, managed requirements are not well quality assurance applied to and regularly refreshed to meet defined architectures financial and service targets Infrastructure architecture is Tiered architectures consistently enforced (Infrastructure and Data Center) have been defined and are being measured and tested for availability, recoverability and performance Distributed architecture set Architectures have been on considered and implemented to harmonized to maximized Return deliver planned service delivery Investment and minimize commitments with tracking Total Cost of Ownership Data Center hierarchies articulated and facilities set up to deliver required services with requisite physical security

TABLE 110 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: Service and Management Operations - Technology Operations Infrastructure Services Governance Basic Competitive Market Leading Business requirements for Availability requirements Availability requirements availability exist but are not documented but not effectively determined jointly by business documented or communicated monitored or measured and service provider, based on cost per level of availability Ad hoc planning efforts to set Availability requirements not Availability requirements balance and monitor availability with no based on baseline data cost against business need plan in place Initial efforts at capacity Availability plan documents Availability strategy reviewed modeling with multiple components as well as business regularly for effectiveness and inconsistent models in place services efficiency The capacity plan has Organization does not have good Availability planning performed fragmented structure, where data to measure whether at service level roles and responsibilities are not availability plan is met beyond clearly defined the component level Basic service continuity Capacity model defined and Capacity modeling is includes restore from back up consistently utilized across all continuously improved via media groups incremental changes Business owners are not Capacity modeling personnel Business users have input to the involved to assess the strategy have access to financial, physical, capacity model based on business impact operational, software, and vendor analysis requirements in order to complete model The plan is a paper document A standard enterprise capacity Capacity planning is continuously that is rarely reviewed plan exists improved via incremental changes over the course of the year The initial builders and testers Plan updated at Capacity planning efforts are able of the IT service continuity plan specified intervals to predict, anticipate, understand, are the only ones trained on it and react rapidly to business changes impacting IT services Some critical business services Business demand forecasts are The strategy is fully supported identified, but not consistent incorporated into the capacity and sponsored by multiple across groups plan executives in the organization to ensure that during a disaster a recovery would be guaranteed within the recovery period agreed upon Service model lacks structure A well documented strategy exists Business/disaster recovery and is paper based; service and agreed upon by business planning and management's dependencies are informally operations and IT software is tied to backup/ understood restore/archive system for metrics reporting and issues tracking Some services are documented, Recovery options have been IT service continuity director but no central catalog exists agreed upon for each business and supporting staff have taken process external training to learn the industry standards for IT service continuity End user experience is The plan is reviewed and audited Critical business service monitored as users report yearly by business and IT documentation is regularly service problems stakeholders reviewed in accordance with changes in business imperatives No performance measure or The plan is an electronic Service model is highly effective targets/objectives set beyond document with links to supporting in predicting the business impact overall costs documents that are updated of technology events regularly with the change management processes. Costs tracked, but inconsistently Training policy is in place for Comprehensive service catalog across groups new recovery team members and jointly reviewed and updated any other personnel that may be between IT and business required in a disaster Risks identified at functional Critical business services are Service Catalog automatically level and for projects documented updated when new configuration item is place in the system No overall account ability for IT Service model is documented End-user experience model risks created and utilized to predict and proactively control user experience Well documented service catalog Balanced set of performance exists measures set, linked directly to business and IT strategy. Service goals clearly support Regular monitoring and proactive critical business services revision of plaan and targets through the year Automated monitoring of end Charges based on services, not user experience technology Clear objectives set for the IT function Focus is mainly on efficiency measures Technology service units costed and used as the basis for recharge Risk management is defined accountability

TABLE 111 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: Strategic IT Technology Operations Alignment - IT Innovation Basic Competitive Market Leading Limited survey of technologies Market leading technologies are Technology scanning is ingrained conducted studied and actively investigated into overall IT and business to potentially enable business processes objectives IT is perceived to Order Taker IT is Solutions Provider IT is Change Agent, leading (“Do what you're told”) (“Bring ideas to the table”) efforts to innovate business practices Limited innovation thinking and IT innovations support business IT serves as Change Agent and innovation is either too early or productivity Leader (“Drive change - out in too late to effectively enable front”) business strategy and growth Ideas and innovations lack Investment levels in innovation IT innovations enable the ownership and follow-through driven by business performance business strategy and support (varies year to year) growth Innovation ideas prioritized Fast Follower' in IT direction Innovation supported by business ad hoc or using a ‘squeaky leadership and direction wheel’ approach The development lifecycle is Innovations are identified through Steady investment as a percentage often slow and inflexible in a range of sources both internal of total IT cost delivering business capability and external usually by a process and often results in reduced of collection benefit capture Innovations adopted at the right point of time ‘Market Leader’

TABLE 112 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: Architecture Management - Technology Operations Manage EDI and Paper Transactions Basic Competitive Market Leading 4.4.3.9.1 Process Web-Based Transactions 4.4.3.9.2 Process EDI Transactions 4.4.3.9.3 Process Paper Transactions 4.4.3.9.4 Manage Quality and Performance of the Transactions Process

TABLE 113 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Capability: Architecture Information Management - Manage Information Technology Operations Systems and Technology and Security Basic Competitive Market Leading 4.4.3.10.1 Plan and Develop Technology Enablement Capabilities 4.4.3.10.2 Manage Application Infrastructure 4.4.3.10.3 Manage Technical Infrastructure 4.4.3.10.4 Manage Hardware Infrastructure 4.4.3.10.5 Manage Quality and Performance of the Information Systems Process 4.4.3.10.6 Govern Information Management 4.4.3.10.7 Identify Knowledge Requirements, Resources, and Gaps 4.4.3.10.8 Collect and Develop Knowledge 4.4.3.10.9 Manage Knowledge Repositories 4.4.3.10.10 Manage User Access & Support of Information Management 4.4.3.10.11 Manage Applications Development, Production & Delivery of Information Management 4.4.3.10.12 Manage Quality and Performance of the Knowledge Management Process

TABLE 114 Global Health and Life Sciences High Performance Capability Assessment Model Public Health Services - Medicaid Enterprise Sub-Platform: Information Capability: IT Governance - Manage Technology Operations Initiatives to Realize Benefits Basic Competitive Market Leading Investments managed IT portfolio monitored and IT portfolio is focused on taking independently with minimal benefits realization calculated actions to proactively optimize consideration of overall IT consistently for key projects on performance against target benefits portfolio completion Investment portfolio actively Limited business participation in Business is engaged in IT managed and measured jointly by IT portfolio management portfolio management for all IT and business continuously functional areas IT and Business strategically Only handful of benefits IT scorecard used to drive IT aligned with focus on identified measurement exists and the steering committee agenda sources of value from IT majority of them are KPIs, typically financial-based, Joint Committees of the operationally-focused for IT Delivery are identified and appropriate senior Business and reported regularly IT leaders are actively engaged in guiding the IT Investment pipeline, portfolio of in-flight projects IT scorecard used to drive IT IT and Business strategically steering committee agenda aligned with focus on identified All IT areas define performance sources of value from IT targets and are tracked on their Joint Committees of the ability to meet these targets appropriate senior Business and IT leaders are actively engaged in guiding the delivery of day-to-day services IT scorecard used to drive IT IT and Business strategically steering committee agenda aligned with focus on identified Rewards typically tied to overall sources of value from IT business performance Joint Committees of the appropriate senior Business and IT leaders are actively engaged in guiding at enterprise, business unit and program/project/service level IT and Business strategically aligned with focus on identified sources of value from IT Refinement of priorities, funding and resource is aligned with accountabilities in the business and with the group's strategic intent

TABLE 115 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: IT Governance - Manage Service Provider Relationships Operations Basic Competitive Market Leading Multiple diverse sourcing strategies in place Enterprise-level sourcing strategy defined, but Sourcing strategy flexible end regularly Little or no controls in place for vendors not consistently followed refreshed based on objectives and degree of relationship management Large or key supplier relationships managed in commoditization Limited contracting rules defined a consolidated manner Coordinated management of supplier Limited vendor performance process and External contracting process defined and relationships aligned with the business/IT metrics are in place applied consistently to key projects sourcing strategy Escalation procedures exist, but not External contracts managed consistently and consistently followed tracked against contracting rules Moritoring and controls for vendor Vendor performance is actively tracked against performance defined and managed within IT external industry performance benchmark Actions taken proactively when potential issues are identified

TABLE 116 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Strategic IT Alignment - Measure Value from IT Operations Basic Competitive Market Leading Ownership and accountability of benefits Ownership and accountability of benefits Ownership and accountability of benefits realization are not clearly defined and realization agreed between the Business and realization shared and agreed between the communicated IT for key projects only Business and IT Benefits realization is considered by business Business managers have limited Responsibilities are clearly defined and well managers to be IT responsibility only responsibility for benefits realization and communicated Some value-based metrics exit for a few accountability Ownership and accountability of benefits simple to define areas Business value metrics connected to IT realization shared and agreed between the No formal communication as to value added by initiatives exist, but not for all functional areas Business and IT IT IT works to ensure that business is aware of Benefits realization is jointly tracked and IT's value add to the enterprise, but not on a managed by IT and the business regular basis Ownership and accountability of benefits realization shared and agreed between the Business and IT Business and IT fully collaborate to ensure that projected benefits will be achieved IT and business metrics used to evaluate business case and impact and serve as input to adjusting estimating methods IT produces IT scorecard and IT quarterly/annual reports to report business value added to the organization

TABLE 117 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Architecture Management - Network Architecture Operations Basic Competitive Market Leading Diverse network architecture in place and Data network architecture in place for WAN, Financial considerations in place for network functional MAN , LAN and Internet. architecture design and implementation Blended cost of service per user reported Configuration Management and Quality Architecture design and management annually Assurance practiced improved to appropriate levels (e.g. best in Network architecture is consistently enforced class) and focus on design, operation optimization and Total Cost of Ownership

TABLE 118 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Architecture Management - Operations Architecture Operations Basic Competitive Market Leading Operations architecture requirements are Operations architecture considered across Active process management for infrastructure documented but without ary review and quality functional units and quality assurance architecture in place control checkpoints practiced in general ITIL fully implemented to manage Technical Patchy architecture decisions mostly individual Operations architecture is consistently Operations, Service Desk and Service Control driven enforced with measurement and adjustments completed Documented inventory of hardware and Integration of hardware and software Service strategy and design process revisited software components components practiced, but still inconsistent annually Rudimentary cost analyses accompany across groups Financial and service targets as key driver of operational architecture development ITIL processes defined and implemented for hardware end software portfolio design Incident, Capacity*, Availability, Operations, Problem, Configuration and Change Hardware and software components are managed to a limited set of service level targets

TABLE 119 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: IT Governance - Plan/Prioritize Initiative Portfolio Operations Basic Competitive Market Leading The are only informal and verbal business Basic initiative prioritization and approval Initiatives are continuously examined by IT and cases for initiatives before they are processes defined and consistently followed Business stakeholders to ensure that implemented Initiatives are defined and evaluated in a investments and budgets are used Risks identified at functional level and for consistent manner appropriately projects. No overall accountability for IT risks Basic initiative prioritization and approval Potential Investments are tracked and Attention to IT-related risks is reactive based processes defined and consistently followed managed through a multi-stage demand on current issues with no overall consideration Initiatives and projects are evaluated pipeline with clear decision gates for magnitude independently with minimal consideration for Initiatives are continuously examined by IT and overlap, resource constraints or conflicts Business stakeholders to ensure that Potential high risk scenarios are identified and investments and budgets are used risk mitigation plans developed appropriately Risk checklist is used in sizing projects and provides a view of future demand and allows initiatives. level of effort invested to scope and shape IT asset inventory is complete and accurate. initiatives to be managed Proactive asset management practices in Initiatives are continuously examined by IT place and Business stakeholders to ensure that investments and budgets are used appropriately Clear visibility of emerging dem and, status and interrelationship of in-flight projects. Initiatives are continuously examined by IT and Business stakeholders to ensure thet investments and budgets are used appropriately Clear visibility of service delivery performance IT risk management is an integral part of all IT processes. External risk audits are conducted and immediately acted upon Potential risks are anticipated well in advance of their occurrence, and systematic changes are instituted to actively manage and mitigate risks based on exposure and potential severity

TABLE 120 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Strategic IT Alignment - Plan and Manage IT Capability Operations Basic Competitive Market Leading IT capabilities are not well documented IT capabilities are well documented and are IT continuously evaluates its application and Minimal capability assessment performed or updated through the change control process infrastructure capabilities to optimize business performed against an inadequate information Capability assessment performed based on the performance for opportunities to reduce costs base current view of the asset portfolio and and improve time to market architecture IT capabilities are cortinuously evaluated end adjusted based on performance against the targeted state and/or changes in progress

TABLE 121 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Solutions Delivery - Program Management Operations Basic Competitive Market Leading Entirely IT driven; limited to no business Project management is equally shared by IT Control over the application of information involvement and business management technology is fully integrated with company's Programs are considered a superset of A separate charter approved by business principal functional units projects exists for the program Joint business and IT steering committee Same processes and deliverables for program Systematic program approval process exists performs program management management as for project management and generally followed Program management part of company No explicit or formal approval at program level Master schedule is clearly delineated into culture, integrating multiple functional Rudimentary master schedule developed releases that are business capability based disciplines to achieve business outcomes Informal program metrics exists, but not well- Program management metrics include some Approval process and evaluation criteria understood value realization actively managed and improved with business Same processes and deliverables for program Program management processes are defined inputs management as for project management - just and focused on interdependence between Proactive planning, review end packaging of all summarized projects projects Program-level reporting is informal Program communications more than simple Business value-based program metrics aggregation- reports progress to achievement continuously monitored jointly with business of overall vision and business results; Program management processes are ingrained separation of project versus program risks and as a part of the enterprise-wide processes issues Program management processes focus on Program reporting at times inconsistent realizing business value and actively managed and improved with business inputs Program milestones and deliverables actively monitored jointly with business Program reporting prompts C-level executives to take appropriate actions

TABLE 122 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Solutions Delivery - Quality Management Operations Basic Competitive Market Leading Quality assurance process is informal Key Processes defined and implemented: Engrained management of stakeholders and Implementation of improvement initiatives not Process Quality Assurance development of stakeholder goals and coordinated or prioritized Solution Quality Management expectations as a guide to process Informal quality standards exists Management of key stakeholders performed improvement Informal quality targets set Planned and coordinated implementation of Process and product QA consistently Customer, client, and employee surveys improvement initiatives managed and tracked. Regular scheduled conducted rarely, survey results inconsistently Quality standards exist, but not consistently reviews of process and product quality. Non- analyzed to and interpreted to guide immediate followed compliance issues is formally communicated improvement activities only Various naming conventions and templates and resolution is implemented Program/project management is evaluated Existence of an organization wide Software based on a balanced scorecard that captures Quality Assurance (SQA) group with a quality productivity and outcome information assure or assigned to each project to ensure Customer, client, end employee surveys process compliance for processes conducted on an ad hoc basis; survey results Standardized set of naming conventions, analyzed and interpreted to guide immediate templates and quality standards exists and improvement activity regularly updated Advanced metrics collected and actively managed with all stakeholders involved Regular customer, client, and employee surveys administered by clear communications; survey results analyzed and interpreted to guide immediate and future improvemert activity

TABLE 123 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Capability: Architecture Management - Security Architecture Operations Basic Competitive Market Leading Security architecture is loosely documented Frameworks such as GIM TS (ISO 13335), Security architecture designed within without quality standards COBIT, and ISO 17799 defined and applied to frameworks to enable and facilitate business One or additional diverse security infrastructures, policies, services and value and provide effective risk management infrastructures, services, policies, standards, operations as well as their management Harmonized security architectures for administration and operations in place Security architecture is consistently followed Infrastructures, policies, services and No cohesion with industry standards or Enterprise security architecture consistently operations acccrding to published frameworks frameworks practiced across groups Business Continuity/Disaster Recovery plans Limited Business Continuity and Disaster Cohesion between utilized standards such as are managed and regularly refreshed to ensure Recovery considerations ISO 17799, for services, policies, operations business success and infrastructure. Business Continuity/Disaster Recovery for defined critical set of applications

TABLE 124 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Operations Capability: Service and Management Operations - Service Delivery Basic Competitive Market Leading Informal, reactive service provided. Service desk is established and processes are Service support process and policies are Fragmented technology, if it exists at all standardized and documented regularly monitored and refreshed using Escalation process may exist, but is Service desk functionality supported by customer input end performance statistics undocumented and is not monitored software and technology that streamlines Tools and technology are regularly reviewed Communication process may exist, but is service and minimizes human involvement and technology scan performed to refresh haphazard, individual effort based Escalation processes are documented and existing tools Ad hoc measurement of service performance applied informally and inconsistently Escalation processes are well structured and No formal agreements on SLAs/OLAs Customer communication process monitored for adherence Availability monitoring is informal and no documented and articulated to the organization Escalation results conveyed back to customer accountability for performance exists Efforts made to inform customers of current Customers are surveyed regularly regarding Ad hoc measurement of service performance service availability overall satisfaction with the service desk Informal reviews of SLAs/OLAs Service requirements for OLAs and SLAs are Customers are surveyed to confirm established satisfaction upon call resolution SLAs/OLAs are measured inconsistently, SLA/OLA monitoring plan specified as part of organization makes the effort but automation contract not developed to the point where Comprehensive service catalog linked to measurements are accurate hierarchy of howservices are related Organization able to catalog services offered OLAs/SLAs for particular service consistent by IT across providers Organization has SLAs/OLAs in place, does End to end monitoring enables accurate not know for certain whether or not they are measurement of business services, bath from met an availability and a performance perspective Service breaches are usually identified, but not Incidents can be linked to services always related back to SLA SLA/OLA monitoring plan specified as part of SLAs/OLAs are written, review schedule is set contract out nobody is responsible for actually following Comprehensive service catalog linked to up. Consequently, updates often do not occur hierarchy of howservices are related or are late OLAs/SLAs for particular service consistent across providers

TABLE 125 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Operations Capability: Service and Management Operations - Service Support Basic Competitive Market Leading Little to no assessment performed prior to Impact analysis performed, service analysis Service introduction approach proactively service introduction and is mostly informal conducted and operability acceptance criteria reviewed with key stakeholders for sign off Support organization readiness assessment defined A service readiness plan is created and informal and ad hoc, mostly individual efforts Support organization is base lined (people, managed detailing a timeline of the key based process, commercial, financial end operational) readiness activities that will need to be Ad hoc development of service related and service readiness assessment performed performed to make organization ready for go- documents, mostly individual efforts based for critical service introductions live of the new services Informal and ad hoc to define configuration Service delivery handover matrix developed Service documents are jointly reviewed with items and processes and documented customers and service introduction team Configuration items loosely identified via ad Business problem identified, process Continuous feedback from customers and hoc methods and are not documented requirements identified and implementation support group utilized to optimize the matrix Initial efforts to identify dependency between approach documented and articulated Configuration management plan proactively configuration management and other functional All configuration items, labels, data sources, reviewed with key stakeholders for sign off and processes with no outcomes data owners and selection criteria clearly is updated on a regular basis Releases done informally, no preplanning identified, documented and articulated Configuration manager assigned to manage except for staff discussions and some testing Efforts to integrate configuration management definition process and involve key stakeholders at individual or group level with some key service management processes for input and sign-off Ad hoc release plans and schedules created Standard procedures for building, Configuration management database and communicated upon request implementing, and configuring of releases are maintained and actively managed Ad hoc release testing performed if any documented and used across the organization Functional processes an integral part of Rollouts done informally, processes vary Release plans and schedules communicated configuration management process, entire between groups across organization process proactively managed for Change process exists, but not formalized Clearly, defined release testing procedures improvements Changes are scheduled, usually according to exist Management review of release plans done on a “scheduled maintenance” windows Rollout plans documented, communicated and regular basis Change discussed informally. Groups meet to utilized throughout the organization Extensive use of tools for work flow, discuss impending changes, but no formal Formal process specified, documented and documentation and builds streamline build methodology for approval enforced process and improve reliability Post implementation check done informally Schedule of changes exists and is available Customers kept aware of impending releases Software licenses are reactively controlled and across the organization along with schedules and work plan renewed only when licenses expire Projected service availability is updated with Release testing feedback proactively integrated Informal audits on an “As Needed” basis scheduled downtime and distributed across to optimize process Problem detection is reactive with process organization Comprehensive rollout plans include dates, initiated by affected users Formal process specified and documented times, back out procedures, components No formalized method far recording reported Change Advisory Board or similar structure is affected, etc. problems designated to approve changes Rollout schedule flexible, can be changed to Escalation process may exist, but it is Standard methodology documented for post accommodate problems identified doing haphazard, undocumented and is not implementation reviews. testing monitored Evaluation criteria for post implementation Changes are prioritized according to industry Incident detection is reactive with process review is identified and established accepted priority levels initiated by affected users Defined and well documented software Proactive change process management using No single point of contact licenses management policies and procedures performance data and user input Incidents resolution is done reactively utilizing across organization. Change schedules proactively reviewed and resources available Software is tracked for license expiration and optimized using performance metrics and user Escalation process may exist, but it is illegal use input haphazard, undocumented and is not Responsibility for tracking and acquiring Users proactively notified of impending monitored licenses is specific and limited to a single changes person or team Change process is proactively monitored and Some audits performed using auto discovery reviewed for enhancements or other tools Financial, technical, business and customer Clear processes defined as to when/how considerations are considered before approval audit are to be performed is granted Problem management system and associated Post implementation review process staffing identified and budget for staffing, continuously reviewed and updated training and support is allocated Post implementation review includes evaluation Problems logged centrally in a database of customer satisfaction derived from customer A formal process for problem escalation feedback emerging, but still inconsistent across groups Organization has processes in place to moritor Incident management system and associated licenses across vendors and operating staffing identified and budget for staffing, systems training and support is allocated Active enforcement of system software Incidents reported reactively to single point of inventory and ability to track down software contact that is not authorized or that does not meet Formal resolution process exists, with security specifications appropriate recording of each step in incident Software inventories on individual systems database monitored via automated technology Responsibilities of each support group are Audits scheduled at intervals specified by documented and well understood across needs of organization organization Mostly automatic, automation runs across Responsibilities of each support group are operating systems and software documented and well understood across Problem management function is integrated organization with incident management and categories, Some form of knowledge base assists impact levels, urgency levels and priority levels resolution process are consistent between the two A formal process of problem escalation exists, Problem resolution process is proactively but not consistently followed across groups reviewed for enhancements Escalation processes are well structured and moritored for adherence The organization tracks problems throughout the lifecycle and knows status at any given time The incident management function is established and operational responsibilities are clearly defined and documented Incidents captured in incident database for reporting and trending Resolution process is reviewed regularly for effectiveness and efficiency Staff is highly trained and cross-trained, with no single person who is the sole expert in a particular area

TABLE 126 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Operations Capability: Solutions Delivery - Systems Building Basic Competitive Market Leading Informal methods exist with loosely defined Systems Development methodolgy exists The standard methodology is flexible enough to requirements and is adhered to at across all projects encompass the full range of project sizes, Each project has a charter and plan Stakeholder expectations formally involved in types and complexities Planning and requirements due diligence is IT planning Incremental benefits explicitly linked to specific driven Requirements are tracked and controlled with requirements and actively managed Build techniques and environment at team change control Post deployment validation a part of enterprise discretion Design documents are tracked and controlled deployment methodology and actively Projects often begin detailed and technical and reviewed with enterprise architecture managed design with limited requirements due diligence board Business realization and linkage of systems Few templates exist and are used Formal reviews/steering meetings at the end of products to benefits integrated into inconsistently each phase methodology Projects have their own processes Unit and system testing formalized and standardized with sign-off Formal development guidelines in place and consistently followed Formal stage gating factors in place

TABLE 127 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Operations Capability: Solutions Delivery - Systems Maintenance Basic Competitive Market Leading Informal systems maintenance processes and Defined service processes for applications Applications assessed for optimal performance standards Consistently followed across groups on a regular basis Only reactive maintenance performed Break-fix activity is separated from Application tiering is frequently reviewed with Large problem back log, no prioritization, no enhancements business regarding business impact maintenance releases Work load is prioritized and triaged weekly SLA metrics are actively tracked and managed No periodic assessment of application portfolio Emergency changes are expedited, other with business implications Informal SLAs exist, but rot-well understood changes are assigned to maintenance or Systems design, operations and user Documentation limited; discretionary development releases documentation is automatically updated as a SLAs exist for critical applications part of configuration management Controlled approach assures documentation is Documentation stored electronically and readily normally updated during projects and available to all groups maintenance No coordination of effort to ensure updates are consistent Document includes functional and technical information

TABLE 128 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Information Technology Operations Capability: Strategic IT Alignment - Value Proposition Development Basic Competitive Market Leading IT is viewed generally as a cost of doing Business executives are looking to enhance IT funds and resources are allocated to business, to automate respective business the use of IT beyond basic process strategic and value-creating operational functions automation, into decision support and patient initiatives There are only informal and verbal business services areas CEO and Board Members actively discuss the cases for initiatives before they are Discretionary spending is usually a percentage IT agenda implemented of IT budget Business case is jointly owned and managed A detailed Business Case is developed at the by business and IT outset with financial measures and metrics (e.g. target run-rate savings) identified, tracked and updated on an ongoing basis

TABLE 129 Global Health and Life Sciences High Performance Capability Assessment Model - Public Health Services - Medicaid Enterprise Sub-Platform: Facilities Management Capability: Manage Facilities and Mail Basic 4.7.1.1 Manage Facilities 4.7.1.2 Manage Mail Functions Manage Intake Manage Internal Distribution Manage Privacy and Security of Mail Manage Processing and Distribution to Postal Service, Private Carriers, etc. 

1. A computer-implemented method for high-performance capability assessment of a Medicaid program, comprising: providing a processor operatively coupled to a communication network; providing one or more databases operatively coupled to the processor and accessible through the communication network; coupling an interface to the processor for receiving input; the processor establishing a machine-readable memory in said one or more databases, including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market Leading’ performance assessment criteria; the processor establishing eligibility determination assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where information is manually validated; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where application data are standardized; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where external and internal validation sources automatically send notice of change in member status; receiving, by the processor, an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; searching, by the processor, the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area; retrieving, by the processor, the matching key assessment performance reference table; analyzing, by the processor, the matching key assessment performance reference table; and obtaining, by the processor, a resultant performance level for the Medicaid program key assessment area.
 2. The method of claim 1, further including establishing eligibility determination assessment criteria, wherein the ‘Basic’ performance assessment criteria includes: a second criteria: The process is constrained by FAMIS or state eligibility system functionality; a third criteria: Staff contact external and internal document verification sources via phone, fax; wherein the ‘Competitive’ performance assessment criteria includes: a second criteria: All programs introduce flexibility within benefit packages; a third criteria: Application data are standardized, all verifications can be automated, rules are consistently applied; wherein the ‘Market Leading’ performance assessment criteria includes: a second criteria: National interoperability permits the eligibility process to send inquiries to any other agency, state, federal, or other entities in any part of the country; and a third criteria: External and internal validation sources automatically send notice of change in member status.
 3. A computer-implemented method for high-performance capability assessment of a Medicaid program, comprising: providing a processor operatively coupled to a communication network; providing one or more databases operatively coupled to the processor and accessible through the communication network; coupling an interface to the processor for receiving input; the processor establishing a machine-readable memory in said one or more databases, including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market Leading’ performance assessment criteria; establishing, by the processor, an enrollment assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where eligibility determination precedes enrollment; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where contractors and provider query a registry to determine eligibility and program enrollment; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where enrollment/eligibility determination processes are automated services triggered by point of service applications; receiving, by the processor, an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; searching, by the processor, the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area; retrieving, by the processor, the matching key assessment performance reference table; analyzing, by the processor, the matching key assessment performance reference table; and obtaining, by the processor, a resultant performance level for the Medicaid program key assessment area.
 4. A computer-implemented method for high-performance capability assessment of a Medicaid program, comprising: providing a processor operatively coupled to a communication network; providing one or more databases operatively coupled to the processor and accessible through the communication network; coupling an interface to the processor for receiving input; the processor establishing a machine-readable memory in said one or more databases, including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market Leading’ performance assessment criteria; establishing, by the processor, a member information management assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where information is researched manually; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where information is shared among entities shared by the agency; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where all authorized data exchange partners are able to access member information; receiving, by the processor, an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; searching, by the processor, the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area; retrieving, by the processor, the matching key assessment performance reference table; analyzing, by the processor, the matching key assessment performance reference table; and obtaining, by the processor, a resultant performance level for the Medicaid program key assessment area.
 5. The method of claim 1, further including establishing a prospective and current member support assessment criteria, wherein the ‘Basic’ performance assessment criteria includes: a first criteria: Member communications are primarily conducted via paper and phone; wherein the ‘Competitive’ performance assessment criteria includes: a first criteria: Member communications are primarily electronic, with paper used only as needed to reach populations; wherein the ‘Market Leading’ performance assessment criteria includes: a first criteria: Certain messages to members are triggered by an individual's entries into personal health records of prospective and current members.
 6. A non-transitory computer-readable memory or data storage means encoded with data representing a computer program for a high-performance capability assessment of a Medicaid program, the computer-readable memory or data storage means causing the computer to perform the acts of: providing a processor operatively coupled to a communication network; providing one or more databases operatively coupled to the processor and accessible through the communication network; coupling an interface to the processor for receiving input; establishing a machine-readable memory in said one or more databases, including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market leading’ performance assessment criteria; establishing, by the processor, an eligibility determination assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where information is manually validated; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where application data are standardized; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria where external and internal validation sources automatically send notice of change in member status; receiving, by the processor, an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; searching, by the processor, the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area; retrieving, by the processor, the matching key assessment performance reference table; analyzing, by the processor, the matching key assessment performance reference table; and obtaining, by the processor, a resultant performance level for the Medicaid program industry key assessment area.
 7. The computer-readable medium of claim 6 further comprising computer-readable content to cause a computer to perform acts of establishing an eligibility determination assessment criteria, wherein the ‘Basic’ performance assessment criteria includes: a second criteria: The process is constrained by FAMIS or state eligibility system functionality; a third criteria: Staff contact external and internal document verification sources via phone, fax; wherein the ‘Competitive’ performance assessment criteria includes: a second criteria: All programs introduce flexibility within benefit packages; a third criteria: Application data is standardized, all verifications can be automated, rules are consistently applied; wherein the ‘Market Leading’ performance assessment criteria includes: a second criteria: National interoperability permits the eligibility process to send inquiries to any other agency, state, federal, or other entities in any part of the country; and a third criteria: External and internal validation sources automatically send notice of change in member status.
 8. A non-transitory computer-readable memory or data storage means encoded with data representing a computer program for a high-performance capability assessment of a Medicaid program, the computer-readable memory or data storage means causing the computer to perform the acts of: providing a processor operatively coupled to a communication network; providing one or more databases operatively coupled to the processor and accessible through the communication network; coupling an interface to the processor for receiving input; establishing a machine-readable memory in said one or more databases, including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market leading’ performance assessment criteria; establishing an enrollment assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where eligibility determination precedes enrollment; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where contractors and provider query a registry to determine eligibility and program enrollment; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where enrollment/eligibility determination processes are automated services triggered by point of service applications; receiving, by the processor, an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; searching, by the processor, the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area; retrieving, by the processor, the matching key assessment performance reference table; analyzing, by the processor, the matching key assessment performance reference table; and obtaining, by the processor, a resultant performance level for the Medicaid program industry key assessment area.
 9. A non-transitory computer-readable memory or data storage means encoded with data representing a computer program for a high-performance capability assessment of a Medicaid program, the computer-readable memory or data storage means causing the computer to perform the acts of: providing a processor operatively coupled to a communication network; providing one or more databases operatively coupled to the processor and accessible through the communication network; coupling an interface to the processor for receiving input; establishing a machine-readable memory in said one or more databases, including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market leading’ performance assessment criteria; establishing a member information management assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where information is researched manually; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where information is shared among entities shared by the agency; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where all authorized data exchange partners are able to access member information; receiving, by the processor, an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; searching, by the processor, the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area; retrieving, by the processor, the matching key assessment performance reference table; analyzing, by the processor, the matching key assessment performance reference table; and obtaining, by the processor, a resultant performance level for the Medicaid program industry key assessment area.
 10. The computer-readable medium of claim 6 further comprising computer-readable content to cause a computer to perform the acts of establishing a prospective and current member support assessment criteria, wherein the ‘Basic’ performance assessment criteria includes: a first criteria: Member communications are primarily conducted via paper and phone; wherein the ‘Competitive’ performance assessment criteria includes: a first criteria: Member communications are primarily electronic, with paper used only as needed to reach populations; wherein the ‘Market Leading’ performance assessment criteria includes: a first criteria: Certain messages to members are triggered by an individual's entries into personal health records of prospective and current members.
 11. A system for high-performance capability assessment of a Medicaid program, comprising: a processor operatively coupled to a communication network; an interface coupled to the processor configured to receive input; one or more databases operatively coupled to the processor and accessible through the communication network; a machine-readable memory operatively located in said one or more databases, said memory including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market leading’ performance assessment criteria; the processor establishing an eligibility determination assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where information is manually validated; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where application data are standardized; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where external and internal validation sources automatically send notice of change in member status; wherein the processor searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table; and wherein the processor performs analysis of the matching key assessment performance reference table; and obtains a resultant performance level for the Medicaid program key assessment area.
 12. The system of claim 11, wherein the processor establishes a, eligibility determination assessment criteria, wherein the ‘Basic’ performance assessment criteria includes: a second criteria: The process is constrained by FAMIS or state eligibility system functionality; a third criteria: Staff contact external and internal document verification sources via phone, fax; wherein the ‘Competitive’ performance assessment criteria includes: a second criteria: All programs introduce flexibility within benefit packages; a third criteria: Application data is standardized, all verifications can be automated, rules are consistently applied; wherein the ‘Market Leading’ performance assessment criteria includes: a second criteria: National interoperability permits the eligibility process to send inquiries to any other agency, state, federal, or other entities in any part of the country; and a third criteria: External and internal validation sources automatically send notice of change in member status.
 13. A system for high-performance capability assessment of a Medicaid program, comprising: a processor operatively coupled to a communication network; an interface coupled to the processor configured to receive input; one or more databases operatively coupled to the processor and accessible through the communication network; a machine-readable memory operatively located in said one or more databases, said memory including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market leading’ performance assessment criteria; the processor establishing an enrollment assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where eligibility determination precedes enrollment; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where contractors and provider query a registry to determine eligibility and program enrollment; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where enrollment/eligibility determination processes are automated services triggered by point of service applications; the interface receiving an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; wherein the processor searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table; and wherein the processor performs analysis of the matching key assessment performance reference table; and obtains a resultant performance level for the Medicaid program key assessment area.
 14. A system for high-performance capability assessment of a Medicaid program, comprising: a processor operatively coupled to a communication network; an interface coupled to the processor configured to receive input; one or more databases operatively coupled to the processor and accessible through the communication network; a machine-readable memory operatively located in said one or more databases, said memory including a multidimensional Medicaid program performance reference set comprising multiple key assessment performance reference tables, at least one key assessment performance reference table defining a member management platform, including: a ‘Basic’ performance level specifying ‘Basic’ performance assessment criteria; a ‘Competitive’ performance level specifying ‘Competitive’ performance assessment criteria; a ‘Market Leading’ performance level specifying ‘Market leading’ performance assessment criteria; the processor establishing a member information management assessment criteria, wherein the ‘Basic’ performance assessment criteria includes a first criteria: where information is researched manually; wherein the ‘Competitive’ performance assessment criteria includes a first criteria: where information is shared among entities shared by the agency; wherein the ‘Market Leading’ performance assessment criteria includes a first criteria: where all authorized data exchange partners are able to access member information; the interface receiving an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis; wherein the processor searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table; and wherein the processor performs analysis of the matching key assessment performance reference table; and obtains a resultant performance level for the Medicaid program key assessment area.
 15. The system of claim 11, wherein the processor establishes a prospective and current member support assessment criteria, wherein the ‘Basic’ performance assessment criteria includes: a first criteria: Member communications are primarily conducted via paper and phone; wherein the ‘Competitive’ performance assessment criteria includes: a first criteria: Member communications are primarily electronic, with paper used only as needed to reach populations; wherein the ‘Market Leading’ performance assessment criteria includes: a first criteria: Certain messages to members are triggered by an individual's entries into personal health records of prospective and current members. 